3 Tier Drug Formulary - 2020 · Index is an alphabetical list of all the drugs in this document....

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with DAKOTACARE.

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3 Tier Drug Formulary - 2020


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DAKOTACARE

2020 3-Tier Drug Formulary

PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN

THIS PLAN. Please refer to your Certificate of Coverage, Master Contract, Plan Document or other plan materials to determine if your drug is covered. The Drug Formulary does not guarantee coverage and is subject to change. The Drug Formulary is subject to change without notice. Members must use participating pharmacies to fill their prescription drugs.


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What is the DAKOTACARE Drug Formulary?

The Drug Formulary is a list of covered prescription drugs, which are approved for use for specific treatments and dispensed through participating pharmacies. DAKOTACARE works with a team of health care providers to choose drugs that provide quality treatment. DAKOTACARE covers drugs on the Drug Formulary that are:

Medically necessary

Approved by the United States Food and Drug Administration (FDA)

Filled at a participating pharmacy For more information on how to fill your prescriptions and determine if your drug is covered, please review your Certificate of Coverage, Master Contract, Plan Document or other plan materials.

Can the Drug Formulary change?

The Drug Formulary may change from time to time as described in the Certificate of Coverage, Master Contract, Plan Document or other plan materials. The enclosed Drug Formulary is the most current Drug Formulary covered by DAKOTACARE. To get updated information about the drugs covered by DAKOTACARE, please visit us online at www.dakotacare.com or call our Service Center toll-free at 1-800-325-5598, 8 a.m. to 5 p.m. CT, Monday through Friday.

How do I use the Drug Formulary?

There are two ways to find your drug on the drug list:

1. Drug Therapeutic Classification or Plain Language Medical Condition

The Drug Formulary starts on page 7. The drugs on this Drug Formulary are grouped by the type of therapeutic class the drugs fall into. These classes of drugs are also grouped with plain language descriptions for the medical conditions for which these drugs aim to treat. For example, drugs used to treat high blood pressure are listed under “Antihypertensives” and “Drugs for the Heart.”

2. Alphabetical Listing

If you are not sure what category to look under, look for your drug in the Index that starts near the end of the formulary document after the drug therapeutic classes have been presented. The Index is an alphabetical list of all the drugs in this document. Both brand-name drugs and generic drugs are in the Index.

Look in the Index and find your drug

Next to your drug, see the page number where you can find coverage information

Turn to the page listed in the Index and find the name of your drug in the first column of the list


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For more information about your DAKOTACARE prescription drug coverage, please look at your Certificate of Coverage, Master Contract, Plan Document or other plan materials. If you have questions about this Drug Formulary, please call our Service Center toll-free at 1-800-325-5598, 8 a.m. to 5 p.m. CT, Monday through Friday. You may also visit us online at www.dakotacare.com

DAKOTACARE Drug Formulary

The Drug Formulary that starts on page 6 gives you information about the drugs covered by DAKOTACARE. A generic drug is a drug that has the same active ingredients as its brand-name counterpart, and has been approved by the FDA as being interchangeable with the brand-name drug as approved by your provider. Upon release of a generic drug to the market, the generic drug will generally be added to the formulary and the associated brand drug will be considered non-preferred or not covered. However, some generic drugs do not cost less than brand-name drugs and may not be added to your formulary.

The first column of the chart lists the drug name. Brand-name drugs are bolded (e.g., Lipitor). Generic drugs are listed in lower-case italics (e.g., atorvastatin). The second column (labeled Drug Tier) will list what tier the drug is placed on in the Drug Formulary. Refer to your Summary of Benefits and Coverage to find the associated co-pay for that drug tier. The information in the Requirements/Limits column tells you if DAKOTACARE has any special requirements for coverage of your drug. These requirements and limits may include:

Preauthorization (PA): DAKOTACARE needs your healthcare provider to get preauthorization for certain drugs. This means that approval from DAKOTACARE must be obtained before you fill your drug. If you don’t get approval, DAKOTACARE will not cover the cost of the drug. Additional information can be found online at www.dakotacare.com.

Quantity Limits (QL): For certain drugs, DAKOTACARE limits the amount of the drug that it will cover. For example, DAKOTACARE only covers 18 tablets of sumatriptan 50mg per 30 days. DAKOTACARE also limits the amount of drugs you may receive within a class of drugs.

These classes have an “§” next to them on the drug list. For these classes, only one drug

should be taken at a time for safety reasons. This may be in addition to a standard one-month or three-month supply.

Step Therapy (ST): DAKOTACARE utilizes step therapy to provide the most cost-effective and safest drugs available for a specific medical condition. Step therapy programs require your healthcare provider to prescribe a step-one drug before a step-two drug will be covered. If the step-one drugs do not work for you, DAKOTACARE will cover the step-two drugs. Visit us online at www.dakotacare.com to review a list of Step Therapy Programs.

Age Limits: Certain drugs approved by the FDA or other prescribing guidelines are not appropriate based on age. In some instances DAKOTACARE may restrict use of certain FDA approved drugs to people within a certain age range.

Gender Limits: Certain drugs approved by the FDA or other prescribing guidelines are not


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appropriate based on gender.

What if my drug is not on the Drug Formulary?

If your drug is not on this Drug Formulary, you have two choices:

Your healthcare provider can prescribe a drug that is similar that is covered on the Drug Formulary. Similar drugs that are preferred and covered on the Drug Formulary may be easier to obtain and lower cost to you.

You can request a formulary exception if you believe the drug you take should be covered because other treatment options on the Drug Formulary do not work for you. To request a formulary exception, you or your healthcare provider must provide written documentation to include the following:

Why no other prescription on the Drug Formulary will work as well as the requested drug,

A list of other drugs that have been tried and how you responded to these drugs

Medical documentation to support the medical necessity

How likely is it that I will get the formulary exception? We will review the information and when a decision has been made, you and your healthcare provider will receive a letter that states the decision. If a formulary exception is approved, the non-preferred co-pay (for the applicable drug type) will be applied. The prescription must be a covered benefit on your plan. Formulary exceptions do not include reductions on prescription co-pays.

What do the tiers mean on the Drug Formulary?

Tier Type of Drugs Included

Tier 0 Preventive drugs (covered at no cost to you)

Tier 1 Generic drugs

Tier 2 Preferred brand drugs

Tier 3 Non-preferred brand drugs

Table of Contents

*Adenosine Receptor Antagonist*** - Drugs For The Nervous System ...........................................................................10*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants* - Drugs For The Nervous System ...................................................10*Aminoglycosides* - Drugs For Infections ......................................................................................................................... 11*Aminomethylcyclines*** - Drugs For Infections ............................................................................................................... 11*Analgesics - Anti-Inflammatory* - Drugs For Pain And Fever .........................................................................................12*Analgesics - Nonnarcotic* - Drugs For Pain And Fever ...................................................................................................14*Analgesics - Opioid* - Drugs For Pain And Fever ............................................................................................................ 15*Androgens-Anabolic* - Hormones ..................................................................................................................................... 18*Anorectal Agents* - Rectal Preparations ...........................................................................................................................19*Anthelmintics* - Drugs For Infections ............................................................................................................................... 19*Antianginal Agents* - Drugs For The Heart .......................................................................................................................19*Antianxiety Agents* - Drugs For The Nervous System ....................................................................................................20*Antiarrhythmics* - Drugs For The Heart ............................................................................................................................20*Antiasthmatic And Bronchodilator Agents* - Drugs For The Lungs .............................................................................. 21*Anticoagulants* - Drugs For The Blood .............................................................................................................................24*Anticonvulsants* - Drugs For The Nervous System .........................................................................................................24*Antidementia Agent Combinations*** - Drugs For The Nervous System .......................................................................28*Antidepressants* - Drugs For The Nervous System ........................................................................................................ 29*Antidiabetics* - Hormones ..................................................................................................................................................31*Antidiarrheal/Probiotic Agents* - Drugs For The Stomach ..............................................................................................33*Antidiarrheals* - Drugs For The Stomach ......................................................................................................................... 34*Antidotes And Specific Antagonists* - Drugs For Overdose Or Poisoning ...................................................................34*Antidotes* - Drugs For Overdose Or Poisoning ............................................................................................................... 34*Antiemetics* - Drugs For The Stomach ............................................................................................................................. 34*Antifungals* - Drugs For Infections ................................................................................................................................... 35*Antihistamines* - Drugs For The Lungs ............................................................................................................................ 36*Antihyperlipidemics* - Drugs For The Heart ..................................................................................................................... 36*Antihypertensives* - Drugs For The Heart ........................................................................................................................ 38*Anti-Infective Agents - Misc.* - Drugs For Infections .......................................................................................................41*Antimalarials* - Drugs For Infections ................................................................................................................................ 41*Antimyasthenic Agents* - Drugs For Nerves And Muscles .............................................................................................42*Antimyasthenic/Cholinergic Agents* - Drugs For Nerves And Muscles ........................................................................ 42*Antimycobacterial Agents* - Drugs For Infections ...........................................................................................................42*Antineoplastic - Bcl-2 Inhibitors*** - Drugs For Cancer ...................................................................................................43*Antineoplastic - Fgfr Kinase Inhibitors*** - Drugs For Cancer ........................................................................................43*Antineoplastic - Methyltransferase Inhibitors*** - Drugs For Cancer .............................................................................43*Antineoplastic - Tropomyosin Receptor Kinase Inhibitors*** - Drugs For Cancer ........................................................43*Antineoplastic - Xpo1 Inhibitors*** - Drugs For Cancer ...................................................................................................43*Antineoplastics And Adjunctive Therapies* - Drugs For Cancer ....................................................................................44*Antiparkinson Agents* - Drugs For The Nervous System ............................................................................................... 48*Antipsychotics/Antimanic Agents* - Drugs For The Nervous System ........................................................................... 49*Antiretrovirals Adjuvants*** - Drugs That Alter Metabolism ............................................................................................51*Antisense Oligonucleotide (Aso) Inhibitor Agents*** - Hormones ..................................................................................52*Antiseptics & Disinfectants* - Antiseptics And Disinfectants .........................................................................................52*Antivirals* - Drugs For Infections .......................................................................................................................................52*Anti-Von Willebrand Factor Agents*** - Drugs For The Blood ........................................................................................ 56*Assorted Classes* - Vitamins And Minerals ..................................................................................................................... 56*Atopic Dermatitis - Monoclonal Antibodies*** - Drugs For The Lungs ...........................................................................58*Beta Blockers* - Drugs For The Heart ............................................................................................................................... 58*Bile Acid Synthesis Disorder Agents*** - Drugs For The Stomach ................................................................................ 59*Biologicals Misc* - Biological Agents ................................................................................................................................59*Calcitonin Gene-Related Peptide (Cgrp) Receptor Antag*** - Drugs For The Nervous System ...................................59*Calcitonin Gene-Related Peptide Receptor Antag (Cgrp)*** - Drugs For The Nervous System ...................................60*Calcium Channel Blockers* - Drugs For The Heart .......................................................................................................... 60*Cardiotonics* - Drugs For The Heart ..................................................................................................................................61*Cardiovascular Agents - Misc.* - Drugs For The Heart .................................................................................................... 61*Cephalosporins* - Drugs For Infections ............................................................................................................................62*Cgrp Receptor Antagonists - Monocolonal Antibodies*** - Drugs For The Nervous System ...................................... 63

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*Chemicals* ........................................................................................................................................................................... 63*Cic Agents - Guanylate Cyclase-C (Gc-C) Agonists*** - Drugs For The Stomach .........................................................64*Contraceptives* - Drugs For Women ................................................................................................................................. 64*Corticosteroids* - Hormones ..............................................................................................................................................65*Cortisol Synthesis Inhibitors*** - Hormones .....................................................................................................................66*Cough/Cold/Allergy* - Drugs For The Lungs .................................................................................................................... 66*Cyclin-Dependent Kinases (Cdk) Inhibitors*** - Drugs For Cancer ................................................................................ 68*Cystic Fibrosis Agent - Combinations*** - Drugs For The Lungs ...................................................................................68*Dermatologicals* - Drugs For The Skin ............................................................................................................................. 68*Diagnostic Products* .......................................................................................................................................................... 81*Dietary Products/Dietary Management Products* - Drugs For Nutrition ........................................................................81*Digestive Aids* - Drugs For The Stomach .........................................................................................................................81*Direct-Acting P2y12 Inhibitors*** - Drugs For The Blood ................................................................................................ 82*Diuretics* - Drugs For The Heart ........................................................................................................................................ 82*Dopamine And Norepinephrine Reuptake Inhibitors (Dnris)*** - Drugs For The Nervous System ..............................83*Endocrine And Metabolic Agents - Misc.* - Hormones ....................................................................................................83*Estrogens* - Hormones .......................................................................................................................................................86*Estrogen-Selective Estrogen Receptor Modulator Comb*** - Hormones .......................................................................87*Farnesoid X Receptor (Fxr) Agonists*** - Drugs For The Liver .......................................................................................87*Fluoroquinolones* - Drugs For Infections .........................................................................................................................87*Gastrointestinal Agents - Misc.* - Drugs For The Stomach .............................................................................................87*Genitourinary Agents - Miscellaneous* - Drugs For The Urinary System ......................................................................89*Glycopeptides*** - Drugs For Infections ............................................................................................................................90*Gout Agents* - Drugs For Pain And Fever ........................................................................................................................ 90*Hematological Agents - Misc.* - Drugs For The Blood .....................................................................................................90*Hematopoietic Agents* - Drugs For Nutrition ................................................................................................................... 91*Hemoglobin S (Hbs) Polymerization Inhibitors*** - Drugs For The Blood ..................................................................... 91*Hemostatics* - Drugs For The Blood ................................................................................................................................. 91*Hepatitis C Agent - Combinations*** - Drugs For Infections ........................................................................................... 92*Hereditary Orotic Aciduria Treatment - Agents** - Drugs That Alter Metabolism ......................................................... 92*Histamine H3-Receptor Antagonist/Inverse Agonists*** - Drugs For The Nervous System ........................................ 92*Hypnotics* - Drugs For The Nervous System ................................................................................................................... 92*Ibs Agent - Mu-Opioid Receptor Agonists*** - Drugs For The Stomach ........................................................................ 93*Insulin-Incretin Mimetic Combinations*** - Hormones .....................................................................................................93*Interleukin-5 Antagonists (Igg1 Kappa)*** - Drugs For The Lungs ................................................................................. 93*Isocitrate Dehydrogenase-1 (Idh1) Inhibitors*** - Drugs For Cancer ..............................................................................93*Isocitrate Dehydrogenase-2 (Idh2) Inhibitors*** - Drugs For Cancer ..............................................................................93*Laxatives* - Drugs For The Stomach ................................................................................................................................. 93*Lymphocyte Function-Associated Antigen-1 (Lfa-1) Antag*** - Drugs For The Eye ..................................................... 94*Macrolides* - Drugs For Infections .................................................................................................................................... 95*Medical Devices* - Medical Supplies And Durable Medical Equipment ......................................................................... 95*Melanocortin Receptor Agonists*** - Drugs For The Nervous System ........................................................................ 103*Migraine Products* - Drugs For The Nervous System ................................................................................................... 103*Minerals & Electrolytes* - Drugs For Nutrition ................................................................................................................104*Mixed Allergenic Extracts*** - Biological Agents ........................................................................................................... 105*Monobactams*** - Drugs For Infections .......................................................................................................................... 105*Mouth/Throat/Dental Agents* - Drugs For The Mouth And Throat ................................................................................105*Multiple Sclerosis Agents - Antimetabolites*** - Drugs For The Nervous System ......................................................106*Multivitamins* - Drugs For Nutrition ................................................................................................................................ 106*Musculoskeletal Therapy Agents* - Drugs For Muscles, Ligaments, Tendons, And Bones ......................................109*Nasal Agents - Systemic And Topical* - Drugs For The Nose .......................................................................................110*Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb*** - Drugs For The Heart .................................................110*Neuromuscular Agents* - Drugs For Nerves And Muscles ........................................................................................... 111*Ophthalmic Agents* - Drugs For The Eye ....................................................................................................................... 111*Orexin Receptor Antagonists*** - Drugs For The Nervous System ..............................................................................115*Otic Agents* - Drugs For The Ear .....................................................................................................................................115*Oxaborole-Related Antifungals - Topical*** - Drugs For The Skin ................................................................................116*Oxytocics* - Hormones ..................................................................................................................................................... 116*Pa Endonuclease Inhibitors*** - Drugs For Infections ................................................................................................... 116*Pcsk9 Inhibitors*** - Drugs For The Heart .......................................................................................................................116

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*Penicillins* - Drugs For Infections ................................................................................................................................... 116*Pharmaceutical Adjuvants* .............................................................................................................................................. 117*Phosphatidylinositol 3-Kinase (Pi3k) Inhibitors*** - Drugs For Cancer ........................................................................118*Phosphodiesterase 4 (Pde4) Inhibitors - Topical*** - Drugs For The Skin ...................................................................119*Phosphodiesterase 4 (Pde4) Inhibitors*** - Drugs For Pain And Fever ........................................................................119*Pleuromutilins*** - Drugs For Infections ......................................................................................................................... 119*Poly (Adp-Ribose) Polymerase (Parp) Inhibitors** - Drugs For Cancer ...................................................................... 119*Poly (Adp-Ribose) Polymerase (Parp) Inhibitors*** - Drugs For Cancer ......................................................................119*Postherpetic Neuralgia (Phn)/Neuropathic Pain Agents*** - Drugs For The Nervous System ...................................119*Potassium Removing Agents*** - Drugs For Nutrition ...................................................................................................119*Prenatal Mv & Minerals W/Fa Without Iron*** - Drugs For Nutrition ............................................................................. 120*Progestins* - Hormones ....................................................................................................................................................120*Protease-Activated Receptor-1 (Par-1) Antagonists*** - Drugs For The Blood ........................................................... 120*Psychotherapeutic And Neurological Agents - Misc.* - Drugs For The Nervous System .......................................... 120*Pulmonary Fibrosis Agents - Kinase Inhibitors*** - Drugs For Cancer ........................................................................123*Pulmonary Fibrosis Agents*** - Drugs For The Lungs .................................................................................................. 123*Pulmonary Hypertension - Prostacyclin Receptor Agonist*** - Drugs For The Heart .................................................123*Respiratory Agents - Misc.* - Drugs For The Lungs .......................................................................................................123*Serotonin 1A Recept Agonist/Serotonin 2A Recept Antag*** - Drugs For The Nervous System .............................. 124*Serotonin Modulators*** - Drugs For The Nervous System ...........................................................................................124*Sglt2 Inhibitor - Dpp-4 Inhibitor Combinations*** - Hormones ......................................................................................124*Sinus Node Inhibitors** - Drugs For The Heart ...............................................................................................................124*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb*** - Hormones ............................................................124*Spleen Tyrosine Kinase (Syk) Inhibitors*** - Drugs For The Blood ..............................................................................124*Steroids - Mouth/Throat/Dental*** - Drugs For The Mouth And Throat ........................................................................ 125*Sulfonamides* - Drugs For Infections ..............................................................................................................................125*Tetracyclines* - Drugs For Infections .............................................................................................................................. 125*Thyroid Agents* - Hormones ............................................................................................................................................ 125*Topical Anesthetic Gases*** - Drugs For The Skin .........................................................................................................126*Toxoids* - Biological Agents ............................................................................................................................................ 126*Transthyretin Stabilizers*** - Hormones ..........................................................................................................................127*Tryptophan Hydroxylase Inhibitors*** - Drugs For The Stomach ................................................................................. 127*Ulcer Drugs* - Drugs For The Stomach ........................................................................................................................... 127*Urinary Anti-Infectives* - Drugs For The Urinary System ..............................................................................................129*Urinary Antispasmodics* - Drugs For The Urinary System ...........................................................................................129*Vaccines* - Biological Agents .......................................................................................................................................... 131*Vaginal Products* - Drugs For Women ............................................................................................................................132*Vasopressors* - Drugs For The Heart ..............................................................................................................................133*Vitamins* - Drugs For Nutrition ........................................................................................................................................ 133

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Drug Name Drug Tier Requirements / Limits

*Adenosine Receptor Antagonist*** - Drugs For The Nervous System

*Adenosine Receptor Antagonist*** - Drugs For The Nervous System

Nourianz Oral Tablet 20 MG, 40 MG 3 QL

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants* - Drugs For The Nervous System

*Adhd Agent - Selective Alpha Adrenergic Agonists*** - Drugs For Attention Deficit Disorder

clonidine hcl er oral tablet extended release 12 hour0.1 mg

1 QL

guanfacine hcl er oral tablet extended release 24 hour1 mg, 2 mg, 3 mg, 4 mg

1QL; Age Restriction Applies (Min 6 Years)

*Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** - Drugs For Attention Deficit Disorder

atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg

1 QL

*Amphetamine Mixtures*** - Drugs For Attention Deficit Disorder

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

1

Mydayis Oral Capsule Extended Release 24 Hour12.5 MG, 25 MG, 37.5 MG, 50 MG

3 QL

*Amphetamines*** - Drugs For Attention Deficit Disorder

Adzenys ER Oral Suspension Extended Release1.25 MG/ML

3Age Restriction Applies (Max 12 Years)

Adzenys XR-ODT Oral Tablet Extended Release Dispersible 12.5 MG, 15.7 MG, 18.8 MG, 3.1 MG, 6.3 MG, 9.4 MG


amphetamine sulfate oral tablet 10 mg, 5 mg 1

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

1

dextroamphetamine sulfate oral solution 5 mg/5ml 1

dextroamphetamine sulfate oral tablet 10 mg, 5 mg 1

Dyanavel XR Oral Suspension Extended Release2.5 MG/ML

3 QL

methamphetamine hcl oral tablet 5 mg 1

Vyvanse Oral Capsule 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

2 QL

Vyvanse Oral Tablet Chewable 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG

2 QL

Zenzedi Oral Tablet 10 MG, 15 MG, 2.5 MG, 20 MG, 30 MG, 5 MG, 7.5 MG

1

*Analeptics*** - Drugs For The Nervous System

caffeine citrate oral solution 20 mg/ml, 60 mg/3ml 1

Last Published: 05/13/2020

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*Stimulants - Misc.*** - Drugs For Attention Deficit Disorder

Aptensio XR Oral Capsule Extended Release 24 Hour 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG

3

armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg

1 PA; QL

Daytrana Transdermal Patch 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR

3

dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg

1

dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg

1

Metadate ER Oral Tablet Extended Release 20 MG 1

methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

1

methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 40 mg, 60 mg

1

methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg

1

methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg, 54 mg

1

methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml 1

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg 1

methylphenidate hcl oral tablet chewable 10 mg, 2.5 mg, 5 mg

1

modafinil oral tablet 100 mg, 200 mg 1 PA; QL

QuilliChew ER Oral Tablet Chewable Extended Release 20 MG, 30 MG, 40 MG

3

*Aminoglycosides* - Drugs For Infections

*Aminoglycosides*** - Antibiotics

Arikayce Inhalation Suspension 590 MG/8.4ML 3 QL

Bethkis Inhalation Nebulization Solution 300 MG/4ML

3 QL

Kitabis Pak Inhalation Nebulization Solution 300 MG/5ML

3 QL

neomycin sulfate oral tablet 500 mg 1

paromomycin sulfate oral capsule 250 mg 1

Tobi Inhalation Nebulization Solution 300 MG/5ML 3 QL

Tobi Podhaler Inhalation Capsule 28 MG 3 QL

tobramycin inhalation nebulization solution 300 mg/5ml

1 QL

*Aminomethylcyclines*** - Drugs For Infections

*Aminomethylcyclines*** - Drugs For Infections

Nuzyra Oral Tablet 150 MG 3


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*Analgesics - Anti-Inflammatory* - Drugs For Pain And Fever

*Antirheumatic - Janus Kinase (Jak) Inhibitors*** - Arthritis And Pain Drugs

Rinvoq Oral Tablet Extended Release 24 Hour 15 MG

2 PA; QL

Xeljanz Oral Tablet 10 MG, 5 MG 2 PA; QL

Xeljanz XR Oral Tablet Extended Release 24 Hour11 MG, 22 MG

2 PA; QL

*Anti-Tnf-Alpha - Monoclonal Antibodies*** - Arthritis And Pain Drugs

Humira Pediatric Crohns Start Subcutaneous Prefilled Syringe Kit 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

2 PA; QL

Humira Pen Subcutaneous Pen-Injector Kit 40 MG/0.4ML, 40 MG/0.8ML

2 PA; QL

Humira Pen-CD/UC/HS Starter Subcutaneous Pen-Injector Kit 40 MG/0.8ML, 80 MG/0.8ML

2 PA; QL

Humira Pen-Ps/UV/Adol HS Start Subcutaneous Pen-Injector Kit 40 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

2 PA; QL

Humira Subcutaneous Prefilled Syringe Kit 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML

2 PA; QL

Simponi Subcutaneous Solution Auto-Injector 100 MG/ML, 50 MG/0.5ML

2 PA; QL

Simponi Subcutaneous Solution Prefilled Syringe100 MG/ML, 50 MG/0.5ML

2 PA; QL

*Anti-Tnf-Alpha - Monoclonoal Antibodies*** - Arthritis And Pain Drugs

Humira Pediatric Crohns Start Subcutaneous Prefilled Syringe Kit 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

2 PA; QL

Humira Pen Subcutaneous Pen-Injector Kit 40 MG/0.4ML, 40 MG/0.8ML

2 PA; QL

Humira Pen-CD/UC/HS Starter Subcutaneous Pen-Injector Kit 40 MG/0.8ML, 80 MG/0.8ML

2 PA; QL

Humira Pen-Ps/UV/Adol HS Start Subcutaneous Pen-Injector Kit 40 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

2 PA; QL

Humira Subcutaneous Prefilled Syringe Kit 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML

2 PA; QL

Simponi Subcutaneous Solution Auto-Injector 100 MG/ML, 50 MG/0.5ML

2 PA; QL

Simponi Subcutaneous Solution Prefilled Syringe100 MG/ML, 50 MG/0.5ML

2 PA; QL


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*Cyclooxygenase 2 (Cox-2) Inhibitors*** - Arthritis And Pain Drugs

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

1 QL

*Gold Compounds*** - Arthritis And Pain Drugs

Ridaura Oral Capsule 3 MG 2

*Interleukin-6 Receptor Inhibitors*** - Arthritis And Pain Drugs

Actemra ACTPen Subcutaneous Solution Auto-Injector 162 MG/0.9ML

2 PA; QL

Actemra Subcutaneous Solution Prefilled Syringe162 MG/0.9ML

2 PA; QL

*Nonsteroidal Anti-Inflammatory Agent Combinations*** - Arthritis And Pain Drugs

diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75-0.2 mg

1

naproxen-esomeprazole oral tablet delayed release375-20 mg, 500-20 mg

1 QL

*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** - Arthritis And Pain Drugs

diclofenac potassium oral tablet 50 mg 1

diclofenac sodium er oral tablet extended release 24 hour 100 mg

1

diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg

1

etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg

1

etodolac oral capsule 200 mg, 300 mg 1

etodolac oral tablet 400 mg, 500 mg 1

fenoprofen calcium oral capsule 200 mg 3

fenoprofen calcium oral capsule 400 mg 1

Fenortho Oral Capsule 200 MG 3

flurbiprofen oral tablet 100 mg, 50 mg 1

IBU Oral Tablet 400 MG, 600 MG, 800 MG 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1

Indocin Oral Suspension 25 MG/5ML 2

Indocin Rectal Suppository 50 MG 2

indomethacin er oral capsule extended release 75 mg 1

indomethacin oral capsule 25 mg, 50 mg 1

ketoprofen er oral capsule extended release 24 hour200 mg

1

ketorolac tromethamine oral tablet 10 mg 1

meclofenamate sodium oral capsule 100 mg, 50 mg 1

mefenamic acid oral capsule 250 mg 1

meloxicam oral tablet 15 mg, 7.5 mg 1


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nabumetone oral tablet 500 mg, 750 mg 1

Nalfon Oral Capsule 400 MG 3

Naprelan Oral Tablet Extended Release 24 Hour750 MG

3

naproxen dr oral tablet delayed release 375 mg, 500 mg

1

naproxen oral suspension 125 mg/5ml 1

naproxen oral tablet 250 mg, 375 mg, 500 mg 1

naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg

1

naproxen sodium oral tablet 275 mg, 550 mg 1

oxaprozin oral tablet 600 mg 1

piroxicam oral capsule 10 mg, 20 mg 1

Sprix Nasal Solution 15.75 MG/SPRAY 3 QL

sulindac oral tablet 150 mg, 200 mg 1

tolmetin sodium oral capsule 400 mg 1

tolmetin sodium oral tablet 600 mg 1

Zipsor Oral Capsule 25 MG 3

*Pyrimidine Synthesis Inhibitors*** - Arthritis And Pain Drugs

leflunomide oral tablet 10 mg, 20 mg 1

*Soluble Tumor Necrosis Factor Receptor Agents*** - Arthritis And Pain Drugs

Enbrel Mini Subcutaneous Solution Cartridge 50 MG/ML

2 PA; QL

Enbrel Subcutaneous Solution Prefilled Syringe 25 MG/0.5ML, 50 MG/ML

2 PA; QL

Enbrel Subcutaneous Solution Reconstituted 25 MG

2 PA; QL

Enbrel SureClick Subcutaneous Solution Auto-Injector 50 MG/ML

2 PA; QL

*Analgesics - Nonnarcotic* - Drugs For Pain And Fever

*Analgesic Combinations*** - Arthritis And Pain Drugs

duraxin oral capsule 300-200-20 mg 1

*Analgesics-Sedatives*** - Arthritis And Pain Drugs

Allzital Oral Tablet 25-325 MG 3

Bupap Oral Tablet 50-300 MG 1 QL

butalbital-acetaminophen oral tablet 50-300 mg, 50-325 mg

1 QL

butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 mg

1 QL

butalbital-apap-caffeine oral tablet 50-325-40 mg 1 QL

butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1


14


Esgic Oral Capsule 50-325-40 MG 1 QL

Tencon Oral Tablet 50-325 MG 1 QL

Vanatol LQ Oral Solution 50-325-40 MG/15ML 3

Vanatol S Oral Solution 50-325-40 MG/15ML 3

Zebutal Oral Capsule 50-325-40 MG 1 QL

*Salicylate Combinations*** - Arthritis And Pain Drugs

choline-mag trisalicylate oral liquid 500 mg/5ml 1

*Salicylates*** - Arthritis And Pain Drugs

diflunisal oral tablet 500 mg 1

salsalate oral tablet 500 mg, 750 mg 1

*Analgesics - Opioid* - Drugs For Pain And Fever

*Codeine Combinations*** - Arthritis And Pain Drugs

acetaminophen-codeine #2 oral tablet 300-15 mg 1QL; Age Restriction Applies (Min 12 Years)



acetaminophen-codeine oral solution 120-12 mg/5ml 1 QL

acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg


Ascomp-Codeine Oral Capsule 50-325-40-30 MG 1QL; Age Restriction Applies (Min 12 Years)

butalbital-apap-caff-cod oral capsule 50-300-40-30 mg 1QL; Age Restriction Applies (Min 12 Years)

butalbital-apap-caff-cod oral capsule 50-325-40-30 mg 1 QL

butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg


*Dihydrocodeine Combinations*** - Arthritis And Pain Drugs

apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg

1

Dvorah Oral Tablet 325-30-16 MG 1 QL

Trezix Oral Capsule 320.5-30-16 MG 1

*Hydrocodone Combinations*** - Arthritis And Pain Drugs

hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml

1 QL

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

1 QL

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

1 QL

Lorcet HD Oral Tablet 10-325 MG 1 QL


15


Lorcet Oral Tablet 5-325 MG 1 QL

Lorcet Plus Oral Tablet 7.5-325 MG 1 QL

Lortab Oral Elixir 10-300 MG/15ML 1 QL

*Opioid Agonists*** - Arthritis And Pain Drugs

Abstral Sublingual Tablet Sublingual 400 MCG, 600 MCG, 800 MCG

3 QL

Arymo ER Oral Tablet Extended Release Abuse-Deterrent 15 MG, 30 MG, 60 MG

3 ST

codeine sulfate oral tablet 30 mg, 60 mg 1QL; Age Restriction Applies (Min 12 Years)

fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg

1 QL

fentanyl citrate buccal tablet 200 mcg, 400 mcg, 600 mcg, 800 mcg

1 QL

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr

1 QL

Fentora Buccal Tablet 100 MCG 3 QL

hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12 mg, 16 mg, 32 mg, 8 mg

1 QL

hydromorphone hcl oral liquid 1 mg/ml 1 QL

hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg 1 QL

hydromorphone hcl rectal suppository 3 mg 1 QL

Hysingla ER Oral Tablet ER 24 Hour Abuse-Deterrent 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

3 ST; QL

Kadian Oral Capsule Extended Release 24 Hour200 MG

3 ST; QL

Lazanda Nasal Solution 100 MCG/ACT, 300 MCG/ACT, 400 MCG/ACT

3 QL

levorphanol tartrate oral tablet 2 mg 1 QL

meperidine hcl oral solution 50 mg/5ml 1 QL

meperidine hcl oral tablet 100 mg, 50 mg 1 QL

Methadone HCl Intensol Oral Concentrate 10 MG/ML

1 QL

methadone hcl oral concentrate 10 mg/ml 1 QL

methadone hcl oral solution 10 mg/5ml, 5 mg/5ml 1 QL

methadone hcl oral tablet 10 mg, 5 mg 1 QL

methadone hcl oral tablet soluble 40 mg 1 QL

Methadose Oral Tablet Soluble 40 MG 1 QL

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml

1 QL

morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg

1


16


morphine sulfate er oral capsule extended release 24 hour 10 mg, 100 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg

1 QL

morphine sulfate er oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg

1 QL

morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml 1 QL

morphine sulfate oral tablet 15 mg, 30 mg 1 QL

morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 mg

1 QL

Nucynta ER Oral Tablet Extended Release 12 Hour100 MG, 150 MG, 200 MG, 250 MG, 50 MG

3 ST; QL

Nucynta Oral Tablet 100 MG, 50 MG, 75 MG 3 QL

Oxaydo Oral Tablet Abuse-Deterrent 5 MG, 7.5 MG 3

oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg

1 QL

oxycodone hcl oral capsule 5 mg 1 QL

oxycodone hcl oral concentrate 100 mg/5ml 1 QL

oxycodone hcl oral solution 5 mg/5ml 1 QL

oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg

1 QL

OxyCONTIN Oral Tablet ER 12 Hour Abuse-Deterrent 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

2 ST; QL

oxymorphone hcl oral tablet 10 mg, 5 mg 1 QL

Subsys Sublingual Liquid 100 MCG, 1200 (600 X 2) MCG, 1600 (800 X 2) MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

3

tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg


tramadol hcl er oral capsule extended release 24 hour150 mg


tramadol hcl er oral tablet extended release 24 hour100 mg, 200 mg, 300 mg


tramadol hcl oral tablet 100 mg, 50 mg 1QL; Age Restriction Applies (Min 12 Years)

Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG

3 ST

Zohydro ER Oral Capsule ER 12 Hour Abuse-Deterrent 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG

3 ST; QL

*Opioid Combinations*** - Arthritis And Pain Drugs

Endocet Oral Tablet 10-325 MG, 2.5-325 MG, 5-325 MG

1 QL

Endocet Oral Tablet 7.5-325 MG 1

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg

1 QL


17


oxycodone-acetaminophen oral tablet 7.5-325 mg 1

oxycodone-aspirin oral tablet 4.8355-325 mg 1 QL

oxycodone-ibuprofen oral tablet 5-400 mg 1 QL

Primlev Oral Tablet 10-300 MG, 5-300 MG, 7.5-300 MG

3

*Opioid Partial Agonists*** - Arthritis And Pain Drugs

Bunavail Buccal Film 2.1-0.3 MG, 4.2-0.7 MG, 6.3-1 MG

3 QL

buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg

1

buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 2-0.5 mg, 4-1 mg, 8-2 mg

1

buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg, 8-2 mg

1

buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr, 7.5 mcg/hr

1 QL

butorphanol tartrate nasal solution 10 mg/ml 1 QL

Butrans Transdermal Patch Weekly 7.5 MCG/HR 3 ST; QL

pentazocine-naloxone hcl oral tablet 50-0.5 mg 1 QL

Suboxone Sublingual Film 12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG

3

Zubsolv Sublingual Tablet Sublingual 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG

3

*Tramadol Combinations*** - Arthritis And Pain Drugs

tramadol-acetaminophen oral tablet 37.5-325 mg 1QL; Age Restriction Applies (Min 12 Years)

*Androgens-Anabolic* - Hormones

*Androgens*** - Drugs For Men

Androderm Transdermal Patch 24 Hour 2 MG/24HR, 4 MG/24HR

2 Male Only; QL

AndroGel Pump Transdermal Gel 20.25 MG/ACT (1.62%)

2 Male Only; QL

AndroGel Transdermal Gel 20.25 MG/1.25GM (1.62%), 25 MG/2.5GM (1%), 40.5 MG/2.5GM (1.62%), 50 MG/5GM (1%)

2 Male Only; QL

danazol oral capsule 100 mg, 200 mg, 50 mg 1

Jatenzo Oral Capsule 158 MG, 198 MG, 237 MG 3

methitest oral tablet 10 mg 1

methyltestosterone oral capsule 10 mg 1

Striant Buccal 30 MG 3 Male Only; QL

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

1

testosterone enanthate intramuscular solution 200 mg/ml

1


18


testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%)

1

testosterone transdermal solution 30 mg/act 1 Male Only; QL

*Anorectal Agents* - Rectal Preparations

*Intrarectal Steroids*** - Rectal Preparations

Colocort Rectal Enema 100 MG/60ML 1

hydrocortisone rectal enema 100 mg/60ml 1

Uceris Rectal Foam 2 MG/ACT 3

*Nitrate Vasodilating Agents*** - Rectal Preparations

Rectiv Rectal Ointment 0.4 % 3

*Rectal Steroids*** - Rectal Preparations

anucort-hc rectal suppository 25 mg 1

Anusol-HC Rectal Suppository 25 MG 1

Hemmorex-HC Rectal Suppository 25 MG 1

hydrocortisone acetate rectal suppository 25 mg, 30 mg

1

*Anthelmintics* - Drugs For Infections

*Anthelmintics*** - Drugs For Parasites

albendazole oral tablet 200 mg 1

benznidazole oral tablet 100 mg, 12.5 mg 3

Emverm Oral Tablet Chewable 100 MG 3

ivermectin oral tablet 3 mg 1

praziquantel oral tablet 600 mg 1

*Antianginal Agents* - Drugs For The Heart

*Antianginals-Other*** - Drugs For Angina

ranolazine er oral tablet extended release 12 hour1000 mg, 500 mg

1 QL

*Nitrates*** - Drugs For Angina

Dilatrate-SR Oral Capsule Extended Release 40 MG

2

GoNitro Sublingual Packet 400 MCG 3

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 40 mg, 5 mg

1

isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg

1

isosorbide mononitrate oral tablet 10 mg, 20 mg 1

Minitran Transdermal Patch 24 Hour 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

1

Nitro-Bid Transdermal Ointment 2 % 1

Nitro-Dur Transdermal Patch 24 Hour 0.3 MG/HR, 0.8 MG/HR

3


19


nitroglycerin er oral capsule extended release 2.5 mg, 6.5 mg, 9 mg

1

nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg

1

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

1

nitroglycerin translingual solution 0.4 mg/spray 1

NitroMist Translingual Aerosol Solution 400 MCG/SPRAY

3

Nitro-Time Oral Capsule Extended Release 2.5 MG, 6.5 MG, 9 MG

1

*Antianxiety Agents* - Drugs For The Nervous System

*Antianxiety Agents - Misc.*** - Drugs For Anxiety

buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg

1

hydroxyzine hcl oral syrup 10 mg/5ml 1

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg

1

meprobamate oral tablet 200 mg, 400 mg 1

*Benzodiazepines*** - Drugs For Seizures /Personality Disorder/Nerve Pain

alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg

1

ALPRAZolam Intensol Oral Concentrate 1 MG/ML 1

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 1

alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg

1

alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg

1

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg 1

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg

1

Diazepam Intensol Oral Concentrate 5 MG/ML 1

diazepam oral concentrate 5 mg/ml 1

diazepam oral solution 5 mg/5ml 1

diazepam oral tablet 10 mg, 2 mg, 5 mg 1

LORazepam Intensol Oral Concentrate 2 MG/ML 1

lorazepam oral concentrate 2 mg/ml 1

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1

oxazepam oral capsule 10 mg, 15 mg, 30 mg 1

*Antiarrhythmics* - Drugs For The Heart

*Antiarrhythmics Type I-A*** - Drugs For Abnormal Heart Rhythms

disopyramide phosphate oral capsule 100 mg, 150 mg 1


20


Norpace CR Oral Capsule Extended Release 12 Hour 100 MG, 150 MG

3

quinidine gluconate er oral tablet extended release324 mg

1

quinidine sulfate oral tablet 200 mg, 300 mg 1

*Antiarrhythmics Type I-B*** - Drugs For Abnormal Heart Rhythms

mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg 1

*Antiarrhythmics Type I-C*** - Drugs For Abnormal Heart Rhythms

flecainide acetate oral tablet 100 mg, 150 mg, 50 mg 1

propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg

1

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg 1

*Antiarrhythmics Type Iii*** - Drugs For Abnormal Heart Rhythms

amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg 1

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg 1

Multaq Oral Tablet 400 MG 3 QL

Pacerone Oral Tablet 100 MG, 200 MG, 400 MG 1

*Antiasthmatic And Bronchodilator Agents* - Drugs For The Lungs

*5-Lipoxygenase Inhibitors*** - Drugs For Asthma/Copd

zileuton er oral tablet extended release 12 hour 600 mg

1 QL

Zyflo Oral Tablet 600 MG 3 QL

*Adrenergic Combinations*** - Drugs For Asthma/Copd

Advair Diskus Inhalation Aerosol Powder Breath Activated 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE

1 QL

Advair HFA Inhalation Aerosol 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT

2 QL

Anoro Ellipta Inhalation Aerosol Powder Breath Activated 62.5-25 MCG/INH

2 QL

Bevespi Aerosphere Inhalation Aerosol 9-4.8 MCG/ACT

2 QL

Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 MCG/INH, 200-25 MCG/INH

2 QL

Combivent Respimat Inhalation Aerosol Solution20-100 MCG/ACT

2 QL

ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml

1

Stiolto Respimat Inhalation Aerosol Solution 2.5-2.5 MCG/ACT

2 QL


21


Symbicort Inhalation Aerosol 160-4.5 MCG/ACT, 80-4.5 MCG/ACT

2 QL

Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/INH

2 QL

Wixela Inhub Inhalation Aerosol Powder Breath Activated 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE

Not Covered

*Anti-Inflammatory Agents*** - Drugs For Asthma/Copd

cromolyn sodium inhalation nebulization solution 20 mg/2ml

1

*Beta Adrenergics*** - Drugs For Asthma/Copd

albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 mg

1

albuterol sulfate hfa inhalation aerosol solution 108 (90 base) mcg/act

1 QL

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml

1

albuterol sulfate oral syrup 2 mg/5ml 1

albuterol sulfate oral tablet 2 mg, 4 mg 1

Arcapta Neohaler Inhalation Capsule 75 MCG 3 QL

Brovana Inhalation Nebulization Solution 15 MCG/2ML

3 QL

levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml

1

levalbuterol tartrate inhalation aerosol 45 mcg/act 1 QL

metaproterenol sulfate oral syrup 10 mg/5ml 1

Perforomist Inhalation Nebulization Solution 20 MCG/2ML

3 QL

ProAir Digihaler Inhalation Aerosol Powder Breath Activated 108 MCG/ACT

2 QL

ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT

2 QL

ProAir RespiClick Inhalation Aerosol Powder Breath Activated 108 (90 Base) MCG/ACT

2 QL

Proventil HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT

3 ST; QL

Serevent Diskus Inhalation Aerosol Powder Breath Activated 50 MCG/DOSE

2 QL

Striverdi Respimat Inhalation Aerosol Solution 2.5 MCG/ACT

3 QL

terbutaline sulfate oral tablet 2.5 mg, 5 mg 1

Ventolin HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT

2 QL


22


*Bronchodilators - Anticholinergics*** - Drugs For Asthma/Copd

Atrovent HFA Inhalation Aerosol Solution 17 MCG/ACT

2 QL

Incruse Ellipta Inhalation Aerosol Powder Breath Activated 62.5 MCG/INH

2 QL

ipratropium bromide inhalation solution 0.02 % 1

Seebri Neohaler Inhalation Capsule 15.6 MCG 3

Spiriva HandiHaler Inhalation Capsule 18 MCG 2 QL

Spiriva Respimat Inhalation Aerosol Solution 1.25 MCG/ACT, 2.5 MCG/ACT

2 QL

Tudorza Pressair Inhalation Aerosol Powder Breath Activated 400 MCG/ACT

3 QL

*Leukotriene Receptor Antagonists*** - Drugs For Asthma/Copd

montelukast sodium oral packet 4 mg 1QL; Age Restriction Applies (Max 5 Years)

montelukast sodium oral tablet 10 mg 1 QL

montelukast sodium oral tablet chewable 4 mg, 5 mg 1

zafirlukast oral tablet 10 mg, 20 mg 1 QL

*Selective Phosphodiesterase 4 (Pde4) Inhibitors*** - Drugs For Asthma/Copd

Daliresp Oral Tablet 250 MCG, 500 MCG 3 QL

*Steroid Inhalants*** - Drugs For Asthma/Copd

Arnuity Ellipta Inhalation Aerosol Powder Breath Activated 100 MCG/ACT, 200 MCG/ACT

2 QL

Arnuity Ellipta Inhalation Aerosol Powder Breath Activated 50 MCG/ACT

2QL; Age Restriction Applies (Min 5 Years and Max 11 Years)

Asmanex (120 Metered Doses) Inhalation Aerosol Powder Breath Activated 220 MCG/INH

2


2

Asmanex (30 Metered Doses) Inhalation Aerosol Powder Breath Activated 110 MCG/INH, 220 MCG/INH

2


2


2

Asmanex HFA Inhalation Aerosol 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT

2 QL

budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml

1 QL

Flovent Diskus Inhalation Aerosol Powder Breath Activated 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST

2 QL

Flovent HFA Inhalation Aerosol 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT

2 QL


23


Pulmicort Flexhaler Inhalation Aerosol Powder Breath Activated 180 MCG/ACT, 90 MCG/ACT

2 QL

Qvar RediHaler Inhalation Aerosol Breath Activated 40 MCG/ACT, 80 MCG/ACT

2 QL

*Xanthines*** - Drugs For Asthma/Copd

Elixophyllin Oral Elixir 80 MG/15ML 3

Theo-24 Oral Capsule Extended Release 24 Hour100 MG, 200 MG, 300 MG, 400 MG

3

theophylline er oral tablet extended release 12 hour300 mg, 450 mg

1

theophylline er oral tablet extended release 24 hour400 mg, 600 mg

1

theophylline oral solution 80 mg/15ml 1

*Anticoagulants* - Drugs For The Blood

*Coumarin Anticoagulants*** - Drugs To Prevent Blood Clots

Coumadin Oral Tablet 1 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

3

Jantoven Oral Tablet 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

1

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

1

*Direct Factor Xa Inhibitors*** - Drugs To Prevent Blood Clots

Eliquis DVT/PE Starter Pack Oral Tablet 5 MG 2

Eliquis Oral Tablet 2.5 MG, 5 MG 2

Xarelto Oral Tablet 10 MG, 15 MG, 2.5 MG, 20 MG 2

Xarelto Starter Pack Oral Tablet Therapy Pack 15 & 20 MG

2

*Low Molecular Weight Heparins*** - Drugs To Prevent Blood Clots

enoxaparin sodium injection solution 300 mg/3ml 1 QL

enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml

1 QL

*Synthetic Heparinoid-Like Agents*** - Drugs To Prevent Blood Clots

fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml

1

*Anticonvulsants* - Drugs For The Nervous System

*Ampa Glutamate Receptor Antagonists*** - Drugs For Seizures /Personality Disorder/Nerve Pain

Fycompa Oral Suspension 0.5 MG/ML 3QL; Age Restriction Applies (Min 12 Years)

Fycompa Oral Tablet 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG



24


*Anticonvulsants - Benzodiazepines*** - Drugs For Seizures /Personality Disorder/Nerve Pain

clobazam oral suspension 2.5 mg/ml 1 PA

clobazam oral tablet 10 mg, 20 mg 1 PA

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1

clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

1

Diastat AcuDial Rectal Gel 10 MG, 20 MG 3

Diastat Pediatric Rectal Gel 2.5 MG 3

diazepam rectal gel 10 mg, 2.5 mg, 20 mg 1

Nayzilam Nasal Solution 5 MG/0.1ML 3

Onfi Oral Suspension 2.5 MG/ML 3 PA

Onfi Oral Tablet 10 MG, 20 MG 3 PA

Sympazan Oral Film 10 MG, 20 MG, 5 MG 3 PA

*Anticonvulsants - Misc.*** - Drugs For Seizures /Personality Disorder/Nerve Pain

Aptiom Oral Tablet 200 MG, 400 MG, 600 MG, 800 MG

3 QL

Banzel Oral Suspension 40 MG/ML 2QL; Age Restriction Applies (Max 18 Years)

Banzel Oral Tablet 200 MG, 400 MG 2 QL

Briviact Oral Solution 10 MG/ML 3Age Restriction Applies (Min 16 Years)

Briviact Oral Tablet 10 MG, 100 MG, 25 MG, 50 MG, 75 MG

3Age Restriction Applies (Min 16 Years)

carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg

1

carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg, 400 mg

1

carbamazepine oral suspension 100 mg/5ml 1

carbamazepine oral tablet 200 mg 1

carbamazepine oral tablet chewable 100 mg 1

Carbatrol Oral Capsule Extended Release 12 Hour100 MG, 200 MG, 300 MG

3

Diacomit Oral Capsule 250 MG, 500 MG 3 PA

Diacomit Oral Packet 250 MG, 500 MG 3 PA

Epidiolex Oral Solution 100 MG/ML 3 PA

Epitol Oral Tablet 200 MG 1

gabapentin oral capsule 100 mg, 300 mg, 400 mg 1

gabapentin oral solution 250 mg/5ml, 300 mg/6ml 1

gabapentin oral tablet 600 mg, 800 mg 1

Keppra Oral Solution 100 MG/ML 3

Keppra Oral Tablet 1000 MG, 250 MG, 500 MG, 750 MG

3


25


Keppra XR Oral Tablet Extended Release 24 Hour500 MG, 750 MG

3 QL

LaMICtal ODT Oral Kit 21 x 25 MG & 7 x 50 MG, 25 & 50 & 100 MG, 42 x 50 MG & 14x100 MG

3 QL

LaMICtal ODT Oral Tablet Dispersible 100 MG, 200 MG, 25 MG, 50 MG

3

LaMICtal Oral Tablet 100 MG, 150 MG, 200 MG, 25 MG

3

LaMICtal Oral Tablet Chewable 25 MG, 5 MG 3

LaMICtal Starter Oral Kit 35 x 25 MG, 42 x 25 MG & 7 x 100 MG, 84 x 25 MG & 14x100 MG

3 QL

LaMICtal XR Oral Kit 21 x 25 MG & 7 x 50 MG, 25 & 50 & 100 MG, 50 & 100 & 200 MG

3 QL

LaMICtal XR Oral Tablet Extended Release 24 Hour100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG

3 QL

lamotrigine er oral tablet extended release 24 hour100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

1 QL

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

1

lamotrigine oral tablet chewable 25 mg, 5 mg 1

lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg

1

lamotrigine starter kit-blue oral kit 35 x 25 mg 1 QL

lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg

1 QL

lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg

1 QL

levetiracetam er oral tablet extended release 24 hour500 mg, 750 mg

1 QL

levetiracetam oral solution 100 mg/ml 1

levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg

1

Mysoline Oral Tablet 250 MG, 50 MG 3

Neurontin Oral Capsule 100 MG, 300 MG, 400 MG 3 ST

Neurontin Oral Solution 250 MG/5ML 3 ST

Neurontin Oral Tablet 600 MG, 800 MG 3 ST

oxcarbazepine oral suspension 300 mg/5ml 1

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1

Oxtellar XR Oral Tablet Extended Release 24 Hour150 MG, 300 MG, 600 MG

3

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg

1 QL

pregabalin oral solution 20 mg/ml 1 QL

primidone oral tablet 250 mg, 50 mg 1

Qudexy XR Oral Capsule ER 24 Hour Sprinkle 100 MG, 150 MG, 200 MG, 25 MG, 50 MG

3 QL


26


Roweepra XR Oral Tablet Extended Release 24 Hour 500 MG, 750 MG

1 QL

Subvenite Oral Tablet 100 MG, 150 MG, 200 MG, 25 MG

1

Subvenite Starter Kit-Blue Oral Kit 35 x 25 MG 1 QL

Subvenite Starter Kit-Green Oral Kit 84 x 25 MG & 14x100 MG

1 QL

Subvenite Starter Kit-Orange Oral Kit 42 x 25 MG & 7 x 100 MG

1 QL

TEGretol Oral Suspension 100 MG/5ML 3

TEGretol Oral Tablet 200 MG 3

TEGretol-XR Oral Tablet Extended Release 12 Hour 100 MG, 200 MG, 400 MG

3

Topamax Oral Tablet 100 MG, 200 MG, 25 MG, 50 MG

3

Topamax Sprinkle Oral Capsule Sprinkle 15 MG, 25 MG

3

topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, 200 mg, 25 mg, 50 mg

1 QL

topiramate oral capsule sprinkle 15 mg, 25 mg 1

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1

Trileptal Oral Suspension 300 MG/5ML 3

Trileptal Oral Tablet 150 MG, 300 MG, 600 MG 3

Trokendi XR Oral Capsule Extended Release 24 Hour 100 MG, 200 MG, 25 MG, 50 MG

3 QL

Vimpat Oral Solution 10 MG/ML 2 QL

Vimpat Oral Tablet 100 MG, 150 MG, 200 MG, 50 MG

2 QL

Zonegran Oral Capsule 100 MG, 25 MG 3

zonisamide oral capsule 100 mg, 25 mg, 50 mg 1

*Carbamates*** - Drugs For Seizures /Personality Disorder/Nerve Pain

felbamate oral suspension 600 mg/5ml 1

felbamate oral tablet 400 mg, 600 mg 1

Felbatol Oral Suspension 600 MG/5ML 3

Felbatol Oral Tablet 400 MG, 600 MG 3

*Gaba Modulators*** - Drugs For Seizures /Personality Disorder/Nerve Pain

Gabitril Oral Tablet 2 MG, 4 MG 3

Sabril Oral Packet 500 MG 3 QL

Sabril Oral Tablet 500 MG 2 QL

tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg 1

vigabatrin oral packet 500 mg 1 QL

vigabatrin oral tablet 500 mg 1 QL

Vigadrone Oral Packet 500 MG 1 QL


27


*Hydantoins*** - Drugs For Seizures /Personality Disorder/Nerve Pain

Dilantin Infatabs Oral Tablet Chewable 50 MG 3

Dilantin Oral Capsule 100 MG, 30 MG 3

Dilantin Oral Suspension 125 MG/5ML 3

Peganone Oral Tablet 250 MG 3

Phenytek Oral Capsule 200 MG, 300 MG 1

Phenytoin Infatabs Oral Tablet Chewable 50 MG 1

phenytoin oral suspension 125 mg/5ml 1

phenytoin oral tablet chewable 50 mg 1

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

1

*Succinimides*** - Drugs For Seizures /Personality Disorder/Nerve Pain

Celontin Oral Capsule 300 MG 2

ethosuximide oral capsule 250 mg 1

ethosuximide oral solution 250 mg/5ml 1

Zarontin Oral Capsule 250 MG 3

Zarontin Oral Solution 250 MG/5ML 3

*Valproic Acid*** - Drugs For Seizures /Personality Disorder/Nerve Pain

Depakote ER Oral Tablet Extended Release 24 Hour 250 MG, 500 MG

3

Depakote Oral Tablet Delayed Release 125 MG, 250 MG, 500 MG

3

Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG

3

divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg

1

divalproex sodium oral capsule delayed release sprinkle 125 mg

1

divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg

1

valproic acid oral capsule 250 mg 1

valproic acid oral solution 250 mg/5ml 1

*Antidementia Agent Combinations*** - Drugs For The Nervous System

*Antidementia Agent Combinations*** - Drugs For The Nervous System

Namzaric Oral Capsule ER 24 Hour Therapy Pack 7 & 14 & 21 &28 -10 MG

2 QL

Namzaric Oral Capsule Extended Release 24 Hour14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG

2 QL


28


*Antidepressants* - Drugs For The Nervous System

*Alpha-2 Receptor Antagonists (Tetracyclics)*** - Drugs For Depression

mirtazapine oral tablet 15 mg, 30 mg, 45 mg 1

mirtazapine oral tablet 7.5 mg 1 QL

mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg

1 QL

*Antidepressants - Misc.*** - Drugs For Depression

Aplenzin Oral Tablet Extended Release 24 Hour174 MG, 348 MG, 522 MG

3 QL

bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg, 200 mg

1

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

1 QL

bupropion hcl oral tablet 100 mg, 75 mg 1

maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg 1

*Modified Cyclics*** - Drugs For Depression

nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

1

trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg

1

Trintellix Oral Tablet 10 MG, 20 MG, 5 MG 2 QL

Viibryd Oral Tablet 10 MG, 20 MG, 40 MG 2 QL

Viibryd Starter Pack Oral Kit 10 & 20 MG 2 QL

*Monoamine Oxidase Inhibitors (Maois)*** - Drugs For Depression

Emsam Transdermal Patch 24 Hour 12 MG/24HR, 6 MG/24HR, 9 MG/24HR

3 QL

Marplan Oral Tablet 10 MG 3

phenelzine sulfate oral tablet 15 mg 1

tranylcypromine sulfate oral tablet 10 mg 1

*Selective Serotonin Reuptake Inhibitors (Ssris)*** - Drugs For Depression

citalopram hydrobromide oral solution 10 mg/5ml 1

citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg

1

escitalopram oxalate oral solution 5 mg/5ml 1

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg 1

fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg 1

fluoxetine hcl oral capsule delayed release 90 mg 1

fluoxetine hcl oral solution 20 mg/5ml 1

fluoxetine hcl oral tablet 10 mg, 20 mg, 60 mg 1

fluvoxamine maleate er oral capsule extended release 24 hour 100 mg, 150 mg

1 QL


29


fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg 1

paroxetine hcl er oral tablet extended release 24 hour12.5 mg, 25 mg, 37.5 mg

1

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg 1

Paxil Oral Suspension 10 MG/5ML 3

Pexeva Oral Tablet 10 MG, 20 MG, 30 MG, 40 MG 3 QL

sertraline hcl oral concentrate 20 mg/ml 1

sertraline hcl oral tablet 100 mg, 25 mg, 50 mg 1

*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** - Drugs For Depression

desvenlafaxine er oral tablet extended release 24 hour100 mg, 50 mg

3 ST; QL

desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg, 25 mg, 50 mg

1 QL

duloxetine hcl oral capsule delayed release particles20 mg, 30 mg, 60 mg

1

Fetzima Oral Capsule Extended Release 24 Hour120 MG, 20 MG, 40 MG, 80 MG

3

Fetzima Titration Oral Capsule ER 24 Hour Therapy Pack 20 & 40 MG

3 QL

venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg

1

venlafaxine hcl er oral tablet extended release 24 hour150 mg, 225 mg, 37.5 mg, 75 mg

1

venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

1

*Tricyclic Agents*** - Drugs For Depression

amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg 1

clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg 1

desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1

doxepin hcl oral concentrate 10 mg/ml 1

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1

imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg

1

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg

1

nortriptyline hcl oral solution 10 mg/5ml 1

protriptyline hcl oral tablet 10 mg, 5 mg 1

trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg

1


30


*Antidiabetics* - Hormones

*Alpha-Glucosidase Inhibitors*** - Drugs For Diabetes

acarbose oral tablet 100 mg, 25 mg, 50 mg 1

miglitol oral tablet 100 mg, 25 mg, 50 mg 1

*Antidiabetic - Amylin Analogs*** - Drugs For Diabetes

SymlinPen 120 Subcutaneous Solution Pen-Injector 2700 MCG/2.7ML

3 QL

SymlinPen 60 Subcutaneous Solution Pen-Injector1500 MCG/1.5ML

3 QL

*Biguanides*** - Drugs For Diabetes

metformin hcl er oral tablet extended release 24 hour500 mg, 750 mg

1

metformin hcl oral solution 500 mg/5ml 3

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg 1

Riomet ER Oral Suspension Reconstituted ER 500 MG/5ML

3

Riomet Oral Solution 500 MG/5ML 3

*Diabetic Other*** - Drugs For Diabetes

Baqsimi One Pack Nasal Powder 3 MG/DOSE 3

Baqsimi Two Pack Nasal Powder 3 MG/DOSE 3

diazoxide oral suspension 50 mg/ml 1

GlucaGen HypoKit Injection Solution Reconstituted 1 MG

2

Glucagon Emergency Injection Kit 1 MG 2

*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** - Drugs For Diabetes

alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg

1 QL

Januvia Oral Tablet 100 MG, 25 MG, 50 MG 2 QL

*Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** - Drugs For Diabetes

alogliptin-metformin hcl oral tablet 12.5-1000 mg, 12.5-500 mg

1 QL

Janumet Oral Tablet 50-1000 MG, 50-500 MG 2 QL

Janumet XR Oral Tablet Extended Release 24 Hour100-1000 MG, 50-1000 MG, 50-500 MG

2 QL

*Dopamine Receptor Agonists - Ergot Derivatives*** - Drugs For Diabetes

Cycloset Oral Tablet 0.8 MG 3

*Dpp-4 Inhibitor-Thiazolidinedione Combinations*** - Drugs For Diabetes

alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25-45 mg

1


31


*Human Insulin*** - Drugs For Diabetes

Fiasp FlexTouch Subcutaneous Solution Pen-Injector 100 UNIT/ML

2

Fiasp PenFill Subcutaneous Solution Cartridge100 UNIT/ML

2

Fiasp Subcutaneous Solution 100 UNIT/ML 2

HumuLIN R U-500 (CONCENTRATED) Subcutaneous Solution 500 UNIT/ML

2

HumuLIN R U-500 KwikPen Subcutaneous Solution Pen-Injector 500 UNIT/ML

2

Lantus SoloStar Subcutaneous Solution Pen-Injector 100 UNIT/ML

2

Lantus Subcutaneous Solution 100 UNIT/ML 2

NovoLIN 70/30 Subcutaneous Suspension (70-30) 100 UNIT/ML

2

NovoLIN N FlexPen Subcutaneous Suspension Pen-Injector 100 UNIT/ML

2

NovoLIN N Subcutaneous Suspension 100 UNIT/ML

2

NovoLIN R FlexPen Injection Solution Pen-Injector100 UNIT/ML

2

NovoLIN R Injection Solution 100 UNIT/ML 2

NovoLOG FlexPen Subcutaneous Solution Pen-Injector 100 UNIT/ML

2

NovoLOG Mix 70/30 FlexPen Subcutaneous Suspension Pen-Injector (70-30) 100 UNIT/ML

3

NovoLOG Mix 70/30 Subcutaneous Suspension(70-30) 100 UNIT/ML

3

NovoLOG PenFill Subcutaneous Solution Cartridge 100 UNIT/ML

2

NovoLOG Subcutaneous Solution 100 UNIT/ML 2

Toujeo Max SoloStar Subcutaneous Solution Pen-Injector 300 UNIT/ML

2

Toujeo SoloStar Subcutaneous Solution Pen-Injector 300 UNIT/ML

2

*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** - Drugs For Diabetes

Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous Solution Pen-Injector 2 MG/1.5ML

2 ST; QL

Ozempic (1 MG/DOSE) Subcutaneous Solution Pen-Injector 2 MG/1.5ML

2 ST; QL

Rybelsus Oral Tablet 14 MG, 3 MG, 7 MG 3 ST; QL

Trulicity Subcutaneous Solution Pen-Injector 0.75 MG/0.5ML, 1.5 MG/0.5ML

2 ST; QL

Victoza Subcutaneous Solution Pen-Injector 18 MG/3ML

2 ST; QL


32


*Meglitinide Analogues*** - Drugs For Diabetes

nateglinide oral tablet 120 mg, 60 mg 1

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 1

*Progesterone Receptor Antagonists*** - Drugs For Diabetes

Korlym Oral Tablet 300 MG 3PA; Age Restriction Applies (Min 18 Years)

*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** - Drugs For Diabetes

Farxiga Oral Tablet 10 MG, 5 MG 2 ST; QL

Jardiance Oral Tablet 10 MG, 25 MG 2 ST; QL

*Sulfonylurea-Biguanide Combinations*** - Drugs For Diabetes

glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

1

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg

1

*Sulfonylureas*** - Drugs For Diabetes

glimepiride oral tablet 1 mg, 2 mg, 4 mg 1

glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg

1

glipizide oral tablet 10 mg, 5 mg 1

glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg

1

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg 1

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg 1

tolbutamide oral tablet 500 mg 1

*Sulfonylurea-Thiazolidinedione Combinations*** - Drugs For Diabetes

pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg

1 QL

*Thiazolidinedione-Biguanide Combinations*** - Drugs For Diabetes

pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg

1

*Thiazolidinediones*** - Drugs For Diabetes

Avandia Oral Tablet 2 MG, 4 MG 3

pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg 1

*Antidiarrheal/Probiotic Agents* - Drugs For The Stomach

*Antidiarrheal/Probiotic Combinations*** - Drugs For Diarrhea

Restora RX Oral Capsule 60-1.25 MG 3


33


*Antidiarrheals* - Drugs For The Stomach

*Antidiarrheal - Chloride Channel Antagonists*** - Drugs For Diarrhea

Mytesi Oral Tablet Delayed Release 125 MG 3 PA; QL

*Antidiarrheal Combinations*** - Drugs For Diarrhea

Restora RX Oral Capsule 60-1.25 MG 3

*Antiperistaltic Agents*** - Drugs For Diarrhea

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml 1

diphenoxylate-atropine oral tablet 2.5-0.025 mg 1

Motofen Oral Tablet 1-0.025 MG 3

opium oral tincture 10 mg/ml (1%) 1

*Antidotes And Specific Antagonists* - Drugs For Overdose Or Poisoning

*Antidotes And Specific Antagonists*** - Drugs For Overdose Or Poisoning

Vistogard Oral Packet 10 GM 3 QL

*Antidotes* - Drugs For Overdose Or Poisoning

*Antidotes - Chelating Agents*** - Drugs For Overdose Or Poisoning

Chemet Oral Capsule 100 MG 3

deferasirox oral tablet 360 mg, 90 mg 1 PA

deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg

1 PA

Exjade Oral Tablet Soluble 125 MG, 250 MG, 500 MG

2 PA

Ferriprox Oral Solution 100 MG/ML 3 PA

Ferriprox Oral Tablet 1000 MG, 500 MG 3 PA

Jadenu Oral Tablet 180 MG, 360 MG, 90 MG 3 PA

Jadenu Sprinkle Oral Packet 180 MG, 360 MG, 90 MG

3 PA

pentetate calcium trisodium combination solution 200 mg/ml

3

pentetate zinc trisodium combination solution 200 mg/ml

3

*Antidotes*** - Drugs For Overdose Or Poisoning

Vistogard Oral Packet 10 GM 3 QL

*Opioid Antagonists*** - Drugs For Overdose Or Poisoning

naltrexone hcl oral tablet 50 mg 1

Narcan Nasal Liquid 4 MG/0.1ML 3 QL

*Antiemetics* - Drugs For The Stomach

*5-Ht3 Receptor Antagonists*** - Drugs For Vomiting And Nausea

Anzemet Oral Tablet 100 MG, 50 MG 3 QL


34


granisetron hcl oral tablet 1 mg 1 QL

ondansetron hcl oral solution 4 mg/5ml 1 QL

ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg 1 QL

ondansetron oral tablet dispersible 4 mg, 8 mg 1 QL

Sancuso Transdermal Patch 3.1 MG/24HR 3 QL

*Antiemetic Combinations*** - Drugs For Vomiting And Nausea

Akynzeo Oral Capsule 300-0.5 MG 3 QL

Coca Cola Oral Syrup 3

*Antiemetics - Anticholinergic*** - Drugs For Vomiting And Nausea

scopolamine transdermal patch 72 hour 1 mg/3days 1 QL

trimethobenzamide hcl oral capsule 300 mg 1

*Antiemetics - Miscellaneous*** - Drugs For Vomiting And Nausea

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 1

Syndros Oral Solution 5 MG/ML 3

*Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** - Drugs For Vomiting And Nausea

aprepitant oral capsule 125 mg, 80 & 125 mg 1 QL

aprepitant oral capsule 40 mg, 80 mg 1

Emend Oral Suspension Reconstituted 125 MG 2 QL

*Antifungals* - Drugs For Infections

*Antifungals*** - Drugs For Fungus

bio-statin oral powder 2

flucytosine oral capsule 250 mg, 500 mg 1

griseofulvin microsize oral suspension 125 mg/5ml 1

griseofulvin microsize oral tablet 500 mg 1

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 1

nystatin oral tablet 500000 unit 1

terbinafine hcl oral tablet 250 mg 1

*Imidazoles*** - Drugs For Fungus

ketoconazole oral tablet 200 mg 1

*Triazoles*** - Drugs For Fungus

Cresemba Oral Capsule 186 MG 3 QL

fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml

1

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg

1

itraconazole oral capsule 100 mg 1 QL

itraconazole oral solution 10 mg/ml 1 QL

Noxafil Oral Suspension 40 MG/ML 2 QL

voriconazole oral suspension reconstituted 40 mg/ml 1 QL


35


voriconazole oral tablet 200 mg, 50 mg 1 QL

*Antihistamines* - Drugs For The Lungs

*Antihistamines - Alkylamines*** - Drugs For Allergies

dexchlorpheniramine maleate oral solution 2 mg/5ml 1

RyClora Oral Solution 2 MG/5ML 1

*Antihistamines - Ethanolamines*** - Drugs For Allergies

carbinoxamine maleate oral solution 4 mg/5ml 1

carbinoxamine maleate oral tablet 4 mg 1

clemastine fumarate oral tablet 2.68 mg 1

Karbinal ER Oral Suspension Extended Release 4 MG/5ML

3

*Antihistamines - Non-Sedating*** - Drugs For Allergies

cetirizine hcl oral tablet 5 mg 1Age Restriction Applies (Max 12 Years)

*Antihistamines - Phenothiazines*** - Drugs For Allergies

Phenadoz Rectal Suppository 12.5 MG, 25 MG 1

promethazine hcl oral solution 6.25 mg/5ml 1

promethazine hcl oral syrup 6.25 mg/5ml 1

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1

promethazine hcl rectal suppository 12.5 mg, 25 mg 1

Promethegan Rectal Suppository 12.5 MG, 25 MG, 50 MG

1

*Antihistamines - Piperidines*** - Drugs For Allergies

cyproheptadine hcl oral syrup 2 mg/5ml 1

cyproheptadine hcl oral tablet 4 mg 1

*Antihyperlipidemics* - Drugs For The Heart

*Antihyperlipidemics - Misc.*** - Drugs For Cholesterol

omega-3-acid ethyl esters oral capsule 1 gm 1 QL

Vascepa Oral Capsule 0.5 GM, 1 GM 3 QL

*Bile Acid Sequestrants*** - Drugs For Cholesterol

cholestyramine light oral packet 4 gm 1

cholestyramine light oral powder 4 gm/dose 1

cholestyramine oral packet 4 gm 1

cholestyramine oral powder 4 gm/dose 1

colesevelam hcl oral packet 3.75 gm 1

colesevelam hcl oral tablet 625 mg 1

colestipol hcl oral granules 5 gm 1

colestipol hcl oral packet 5 gm 1


36


colestipol hcl oral tablet 1 gm 1

Prevalite Oral Packet 4 GM 1

Prevalite Oral Powder 4 GM/DOSE 1

*Fibric Acid Derivatives*** - Drugs For Cholesterol

Antara Oral Capsule 30 MG, 90 MG 3

fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg

1

fenofibrate oral capsule 134 mg, 150 mg, 200 mg, 50 mg, 67 mg

1

fenofibrate oral tablet 120 mg, 145 mg, 160 mg, 40 mg, 48 mg, 54 mg

1

fenofibric acid oral capsule delayed release 135 mg, 45 mg

1

gemfibrozil oral tablet 600 mg 1

*Hmg Coa Reductase Inhibitors*** - Drugs For Cholesterol

Altoprev Oral Tablet Extended Release 24 Hour 20 MG, 40 MG

3

Altoprev Oral Tablet Extended Release 24 Hour 60 MG

3 QL

atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

1 QL

flolipid oral suspension 20 mg/5ml 3

fluvastatin sodium er oral tablet extended release 24 hour 80 mg

1

fluvastatin sodium oral capsule 20 mg, 40 mg 1 QL

Livalo Oral Tablet 1 MG, 2 MG, 4 MG 3 QL

lovastatin oral tablet 10 mg, 20 mg, 40 mg 1 QL

pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

1 QL

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg

1 QL

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg

1 QL

*Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb*** - Drugs For Cholesterol

ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg

1

*Intestinal Cholesterol Absorption Inhibitors*** - Drugs For Cholesterol

ezetimibe oral tablet 10 mg 1

*Microsomal Triglyceride Transfer Protein Inhibitors*** - Drugs For Cholesterol

Juxtapid Oral Capsule 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG

3 PA; QL


37


*Nicotinic Acid Derivatives*** - Drugs For Cholesterol

niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg

1 QL

*Antihypertensives* - Drugs For The Heart

*Ace Inhibitor & Calcium Channel Blocker Combinations*** - Drugs For High Blood Pressure

amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

1

Prestalia Oral Tablet 14-10 MG, 3.5-2.5 MG, 7-5 MG 3

trandolapril-verapamil hcl er oral tablet extended release 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg

1

*Ace Inhibitors & Thiazide/Thiazide-Like*** - Drugs For High Blood Pressure

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

1

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

1

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

1

fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg

1

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

1

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

1

*Ace Inhibitors*** - Drugs For High Blood Pressure

benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

1

Epaned Oral Solution 1 MG/ML 3

fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

1

moexipril hcl oral tablet 15 mg, 7.5 mg 1

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1

Qbrelis Oral Solution 1 MG/ML 3

quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1

trandolapril oral tablet 1 mg, 2 mg, 4 mg 1

*Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** - Drugs For High Blood Pressure

methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg

1


38


*Agents For Pheochromocytoma*** - Drugs For High Blood Pressure

Demser Oral Capsule 250 MG 3

phenoxybenzamine hcl oral capsule 10 mg 1

*Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** - Drugs For High Blood Pressure

amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg

1

amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg

1

telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg

1

*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** - Drugs For High Blood Pressure

candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg

1

Edarbyclor Oral Tablet 40-12.5 MG, 40-25 MG 3

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg

1

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

1

olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg

1

telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg

1

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

1

*Angiotensin Ii Receptor Antagonists*** - Drugs For High Blood Pressure

candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg

1

Edarbi Oral Tablet 40 MG, 80 MG 3

irbesartan oral tablet 150 mg, 300 mg, 75 mg 1

losartan potassium oral tablet 100 mg, 25 mg, 50 mg 1

olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg 1

telmisartan oral tablet 20 mg, 40 mg, 80 mg 1

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg 1

*Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides*** - Drugs For High Blood Pressure

amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

1

olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg

1


39


*Antiadrenergics - Centrally Acting*** - Drugs For High Blood Pressure

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1

clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr

1 QL

guanfacine hcl oral tablet 1 mg, 2 mg 1

methyldopa oral tablet 250 mg, 500 mg 1

*Antiadrenergics - Peripherally Acting*** - Drugs For High Blood Pressure

doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg

1

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1

terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1

*Antihypertensives - Misc.*** - Drugs For High Blood Pressure

Vecamyl Oral Tablet 2.5 MG 2

*Beta Blocker & Diuretic Combinations*** - Drugs For High Blood Pressure

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg

1

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

1

Dutoprol Oral Tablet Extended Release 24 Hour100-12.5 MG, 25-12.5 MG, 50-12.5 MG

3

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg, 50-25 mg

1

propranolol-hctz oral tablet 40-25 mg, 80-25 mg 1

Tenoretic 100 Oral Tablet 100-25 MG 3

Tenoretic 50 Oral Tablet 50-25 MG 3

*Direct Renin Inhibitors & Thiazide/Thiazide-Like Comb*** - Drugs For High Blood Pressure

Tekturna HCT Oral Tablet 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG

3 QL

*Direct Renin Inhibitors*** - Drugs For High Blood Pressure

aliskiren fumarate oral tablet 150 mg, 300 mg 1 QL

*Selective Aldosterone Receptor Antagonists (Saras)*** - Drugs For High Blood Pressure

eplerenone oral tablet 25 mg, 50 mg 1 QL

*Vasodilators*** - Drugs For High Blood Pressure

hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

1

minoxidil oral tablet 10 mg, 2.5 mg 1


40


*Anti-Infective Agents - Misc.* - Drugs For Infections

*Anti-Infective Agents - Misc.*** - Drugs For Infections

Aemcolo Oral Tablet Delayed Release 194 MG 3

Impavido Oral Capsule 50 MG 3 QL

metronidazole oral capsule 375 mg 1

metronidazole oral tablet 250 mg, 500 mg 1

Primsol Oral Solution 50 MG/5ML 3

tinidazole oral tablet 250 mg, 500 mg 1

trimethoprim oral tablet 100 mg 1

Xifaxan Oral Tablet 200 MG, 550 MG 2

*Anti-Infective Misc. - Combinations*** - Antibiotics

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml

1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

1

Sulfatrim Pediatric Oral Suspension 200-40 MG/5ML

1

*Antiprotozoal Agents*** - Drugs For Parasites

Alinia Oral Suspension Reconstituted 100 MG/5ML 2

Alinia Oral Tablet 500 MG 2

atovaquone oral suspension 750 mg/5ml 1

*Leprostatics*** - Antibiotics

dapsone oral tablet 100 mg, 25 mg 1

*Lincosamides*** - Antibiotics

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml

1

*Oxazolidinones*** - Antibiotics

linezolid oral suspension reconstituted 100 mg/5ml 1 QL

linezolid oral tablet 600 mg 1 QL

Sivextro Oral Tablet 200 MG 2 QL

*Antimalarials* - Drugs For Infections

*Antimalarial Combinations*** - Drugs For Parasites

atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg

1

Coartem Oral Tablet 20-120 MG 2 QL

*Antimalarials*** - Drugs For Parasites

chloroquine phosphate oral tablet 250 mg, 500 mg 1

Daraprim Oral Tablet 25 MG 3

hydroxychloroquine sulfate oral tablet 200 mg 1


41


mefloquine hcl oral tablet 250 mg 1

primaquine phosphate oral tablet 26.3 mg 1

quinine sulfate oral capsule 324 mg 1 QL

*Antimyasthenic Agents* - Drugs For Nerves And Muscles

*Antimyasthenic Agents*** - Drugs For Nerves And Muscles

Firdapse Oral Tablet 10 MG 3 PA

guanidine hcl oral tablet 125 mg 2

pyridostigmine bromide er oral tablet extended release180 mg

1

pyridostigmine bromide oral solution 60 mg/5ml 1

pyridostigmine bromide oral tablet 60 mg 1

pyridostigmine bromide tablet 30 mg oral 30 mg 1

Ruzurgi Oral Tablet 10 MG 3 PA

*Antimyasthenic/Cholinergic Agents*** - Drugs For Nerves And Muscles




1





*Antimyasthenic/Cholinergic Agents* - Drugs For Nerves And Muscles




1





*Antimycobacterial Agents* - Drugs For Infections

*Anti Tb Combinations*** - Antibiotics

Rifamate Oral Capsule 150-300 MG 3

Rifater Oral Tablet 50-120-300 MG 3

*Antimycobacterial Agents*** - Antibiotics

cycloserine oral capsule 250 mg 1

ethambutol hcl oral tablet 100 mg, 400 mg 1

isoniazid oral syrup 50 mg/5ml 1

isoniazid oral tablet 100 mg, 300 mg 1


42


Paser Oral Packet 4 GM 1

Pretomanid Oral Tablet 200 MG 3

Priftin Oral Tablet 150 MG 3

pyrazinamide oral tablet 500 mg 1

rifabutin oral capsule 150 mg 1

rifampin oral capsule 150 mg, 300 mg 1

Sirturo Oral Tablet 100 MG 3

Trecator Oral Tablet 250 MG 3

*Antineoplastic - Bcl-2 Inhibitors*** - Drugs For Cancer

*Antineoplastic - Bcl-2 Inhibitors*** - Drugs For Cancer

Venclexta Oral Tablet 10 MG, 100 MG, 50 MG 3 PA; QL

Venclexta Starting Pack Oral Tablet Therapy Pack10 & 50 & 100 MG

3 PA; QL

*Antineoplastic - Fgfr Kinase Inhibitors*** - Drugs For Cancer

*Antineoplastic - Fgfr Kinase Inhibitors*** - Drugs For Cancer

Balversa Oral Tablet 3 MG, 4 MG, 5 MG 3 PA

Pemazyre Oral Tablet 13.5 MG, 4.5 MG, 9 MG 3 PA

*Antineoplastic - Methyltransferase Inhibitors*** - Drugs For Cancer

*Antineoplastic - Methyltransferase Inhibitors*** - Drugs For Cancer

Tazverik Oral Tablet 200 MG 3 PA

*Antineoplastic - Tropomyosin Receptor Kinase Inhibitors*** - Drugs For Cancer

*Antineoplastic - Tropomyosin Receptor Kinase Inhibitors*** - Drugs For Cancer

Rozlytrek Oral Capsule 100 MG 3 PA; QL

Rozlytrek Oral Capsule 200 MG 3 PA

Vitrakvi Oral Capsule 100 MG, 25 MG 3 PA

Vitrakvi Oral Solution 20 MG/ML 3 PA

*Antineoplastic - Xpo1 Inhibitors*** - Drugs For Cancer

*Antineoplastic - Xpo1 Inhibitors*** - Drugs For Cancer

Xpovio (100 MG Once Weekly) Oral Tablet Therapy Pack 20 MG

3 PA


3 PA


3 PA

Xpovio (80 MG Twice Weekly) Oral Tablet Therapy Pack 20 MG

3 PA


43


*Antineoplastics And Adjunctive Therapies* - Drugs For Cancer

*Alkylating Agents*** - Drugs For Cancer

Myleran Oral Tablet 2 MG 2

*Androgen Biosynthesis Inhibitors*** - Drugs For Cancer

abiraterone acetate oral tablet 250 mg 1 PA; QL

Yonsa Oral Tablet 125 MG 3 PA; QL

Zytiga Oral Tablet 250 MG, 500 MG 3 PA; QL

*Antiadrenals*** - Drugs For Cancer

Lysodren Oral Tablet 500 MG 2 PA

*Antiandrogens*** - Drugs For Cancer

bicalutamide oral tablet 50 mg 1 QL

Erleada Oral Tablet 60 MG 3 PA

flutamide oral capsule 125 mg 1

Nilandron Oral Tablet 150 MG 2 PA

nilutamide oral tablet 150 mg 1 PA

Nubeqa Oral Tablet 300 MG 3 PA; QL

Xtandi Oral Capsule 40 MG 3 PA; QL

*Antiestrogens*** - Drugs For Cancer

Soltamox Oral Solution 10 MG/5ML 3

tamoxifen citrate oral tablet 10 mg, 20 mg 1

toremifene citrate oral tablet 60 mg 1 PA

*Antimetabolites*** - Drugs For Cancer

capecitabine oral tablet 150 mg, 500 mg 1 PA

mercaptopurine oral tablet 50 mg 1

methotrexate oral tablet 2.5 mg 1

methotrexate sodium oral tablet 2.5 mg 1

Purixan Oral Suspension 2000 MG/100ML 3

Tabloid Oral Tablet 40 MG 3 PA

Trexall Oral Tablet 10 MG, 15 MG, 5 MG, 7.5 MG 2

Xatmep Oral Solution 2.5 MG/ML 3

Xeloda Oral Tablet 150 MG, 500 MG 3 PA

*Antineoplastic - Braf Kinase Inhibitors*** - Drugs For Cancer

Braftovi Oral Capsule 75 MG 3 PA; QL

Tafinlar Oral Capsule 50 MG, 75 MG 3 PA; QL

Zelboraf Oral Tablet 240 MG 3 PA; QL

*Antineoplastic - Hedgehog Pathway Inhibitors*** - Drugs For Cancer

Daurismo Oral Tablet 100 MG, 25 MG 3 PA

Erivedge Oral Capsule 150 MG 3 PA; QL

Odomzo Oral Capsule 200 MG 3 PA; QL


44


*Antineoplastic - Histone Deacetylase Inhibitors*** - Drugs For Cancer

Farydak Oral Capsule 10 MG, 20 MG 3 PA; QL

Zolinza Oral Capsule 100 MG 2 PA; QL

*Antineoplastic - Immunomodulators*** - Drugs For Cancer

Pomalyst Oral Capsule 1 MG, 2 MG, 3 MG, 4 MG 3 PA; QL

*Antineoplastic - Mek Inhibitors*** - Drugs For Cancer

Cotellic Oral Tablet 20 MG 3 PA; QL

Koselugo Oral Capsule 10 MG, 25 MG 3 PA

Mekinist Oral Tablet 0.5 MG, 2 MG 2 PA; QL

Mektovi Oral Tablet 15 MG 3 PA; QL

*Antineoplastic - Mtor Kinase Inhibitors*** - Drugs For Cancer

Afinitor Disperz Oral Tablet Soluble 2 MG, 3 MG, 5 MG

2 PA; QL

Afinitor Oral Tablet 10 MG, 2.5 MG, 5 MG, 7.5 MG 2 PA; QL

everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg 1 PA; QL

*Antineoplastic - Multikinase Inhibitors*** - Drugs For Cancer

NexAVAR Oral Tablet 200 MG 2 PA; QL

Rydapt Oral Capsule 25 MG 3 PA

Stivarga Oral Tablet 40 MG 3 PA; QL

Sutent Oral Capsule 12.5 MG, 25 MG, 37.5 MG, 50 MG

2 PA

*Antineoplastic - Proteasome Inhibitors*** - Drugs For Cancer

Ninlaro Oral Capsule 2.3 MG, 3 MG, 4 MG 3 PA; QL

*Antineoplastic - Tyrosine Kinase Inhibitors*** - Drugs For Cancer

Alecensa Oral Capsule 150 MG 2 PA; QL

Alunbrig Oral Tablet 180 MG, 30 MG, 90 MG 3 PA; QL

Alunbrig Oral Tablet Therapy Pack 90 & 180 MG 3 PA; QL

Ayvakit Oral Tablet 100 MG, 200 MG, 300 MG 3 PA

Bosulif Oral Tablet 100 MG, 400 MG, 500 MG 3 PA; QL

Brukinsa Oral Capsule 80 MG 3 PA

Cabometyx Oral Tablet 20 MG, 40 MG, 60 MG 3 PA

Calquence Oral Capsule 100 MG 3 PA

Caprelsa Oral Tablet 100 MG, 300 MG 2 PA; QL

Cometriq (100 mg Daily Dose) Oral Kit 1 X 80 & 1 X 20 MG

3 PA; QL

Cometriq (140 mg Daily Dose) Oral Kit 1 X 80 & 3 X 20 MG

3 PA; QL

Cometriq (60 mg Daily Dose) Oral Kit 20 MG 3 PA; QL


45


erlotinib hcl oral tablet 100 mg, 150 mg, 25 mg 1 PA; QL

Gilotrif Oral Tablet 20 MG, 30 MG, 40 MG 3 PA; QL

Gleevec Oral Tablet 100 MG, 400 MG 3 PA; QL

Iclusig Oral Tablet 15 MG, 45 MG 2 PA; QL

imatinib mesylate oral tablet 100 mg, 400 mg 1 PA; QL

Imbruvica Oral Capsule 140 MG, 70 MG 3 PA; QL

Imbruvica Oral Tablet 140 MG, 280 MG, 420 MG, 560 MG

3 PA; QL

Inlyta Oral Tablet 1 MG, 5 MG 3 PA; QL

Iressa Oral Tablet 250 MG 3 PA

Lenvima (10 MG Daily Dose) Oral Capsule Therapy Pack 10 MG

3 PA; QL

Lenvima (12 MG Daily Dose) Oral Capsule Therapy Pack 3 x 4 MG

3 PA; QL

Lenvima (14 MG Daily Dose) Oral Capsule Therapy Pack 10 & 4 MG

3 PA; QL

Lenvima (18 MG Daily Dose) Oral Capsule Therapy Pack 10 MG & 2 x 4 MG

3 PA; QL


3 PA; QL

Lenvima (24 MG Daily Dose) Oral Capsule Therapy Pack 2 x 10 MG & 4 MG

3 PA; QL

Lenvima (4 MG Daily Dose) Oral Capsule Therapy Pack 4 MG

3 PA; QL


3 PA; QL

Lorbrena Oral Tablet 100 MG, 25 MG 3 PA; QL

Nerlynx Oral Tablet 40 MG 3 PA

Sprycel Oral Tablet 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG

2 PA

Tagrisso Oral Tablet 40 MG, 80 MG 3 PA; QL

Tarceva Oral Tablet 100 MG, 150 MG, 25 MG 2 PA; QL

Tasigna Oral Capsule 150 MG, 200 MG, 50 MG 3 PA; QL

Tukysa Oral Tablet 150 MG 3 PA

Tukysa Oral Tablet 50 MG 3 PA; QL

Turalio Oral Capsule 200 MG 3 PA; QL

Tykerb Oral Tablet 250 MG 2 PA; QL

Vizimpro Oral Tablet 15 MG, 30 MG, 45 MG 3 PA; QL

Votrient Oral Tablet 200 MG 2 PA; QL

Xalkori Oral Capsule 200 MG, 250 MG 3 PA; QL

Xospata Oral Tablet 40 MG 3 PA

Zykadia Tablet 150 MG Oral 150 MG 3 PA; QL


46


*Antineoplastic Combinations*** - Drugs For Cancer

Kisqali Femara (400 MG Dose) Oral Tablet Therapy Pack 200 & 2.5 MG

3 PA

Kisqali Femara (600 MG Dose) Oral Tablet Therapy Pack 200 & 2.5 MG

3 PA

Kisqali Femara(200 MG Dose) Oral Tablet Therapy Pack 200 & 2.5 MG

3 PA

Lonsurf Oral Tablet 15-6.14 MG, 20-8.19 MG 3 PA; QL

*Antineoplastics Misc.*** - Drugs For Cancer

Actimmune Subcutaneous Solution 2000000 UNIT/0.5ML

3 PA

hydroxyurea oral capsule 500 mg 1

Matulane Oral Capsule 50 MG 2 PA

Sylatron Subcutaneous Kit 200 MCG, 300 MCG, 600 MCG

3 PA; QL

*Aromatase Inhibitors*** - Drugs For Cancer

anastrozole oral tablet 1 mg 1 QL

exemestane oral tablet 25 mg 1 PA

letrozole oral tablet 2.5 mg 1

*Estrogens-Antineoplastic*** - Drugs For Cancer

Emcyt Oral Capsule 140 MG 2 PA

*Folic Acid Antagonists Rescue Agents*** - Drugs For Cancer

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

1

*Imidazotetrazines*** - Drugs For Cancer

Temodar Oral Capsule 100 MG, 140 MG, 180 MG, 20 MG, 250 MG, 5 MG

3 PA

temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg

1 PA

*Janus Associated Kinase (Jak) Inhibitors*** - Drugs For Cancer

Inrebic Oral Capsule 100 MG 3 PA; QL

Jakafi Oral Tablet 10 MG, 15 MG, 20 MG, 25 MG, 5 MG

3 PA; QL

*Lhrh Analogs*** - Drugs For Cancer

leuprolide acetate injection kit 1 mg/0.2ml 1 PA

*Mitotic Inhibitors*** - Drugs For Cancer

etoposide oral capsule 50 mg 1

*Nitrogen Mustards*** - Drugs For Cancer

Alkeran Oral Tablet 2 MG 3 PA

cyclophosphamide oral capsule 25 mg, 50 mg 1

Leukeran Oral Tablet 2 MG 2 PA

melphalan oral tablet 2 mg 1 PA


47


*Nitrosoureas*** - Drugs For Cancer

Gleostine Oral Capsule 10 MG, 100 MG, 40 MG 2 PA

*Progestins-Antineoplastic*** - Drugs For Cancer

hydroxyprogesterone caproate intramuscular solution1.25 gm/5ml

1

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml

1

megestrol acetate oral tablet 20 mg, 40 mg 1

*Retinoids*** - Drugs For Cancer

tretinoin oral capsule 10 mg 1 PA

*Selective Retinoid X Receptor Agonists*** - Drugs For Cancer

bexarotene oral capsule 75 mg 1 PA

Targretin Oral Capsule 75 MG 2 PA

*Topoisomerase I Inhibitors*** - Drugs For Cancer

Hycamtin Oral Capsule 0.25 MG, 1 MG 2 PA

*Urinary Tract Protective Agents*** - Drugs For Cancer

Mesnex Oral Tablet 400 MG 3

*Antiparkinson Agents* - Drugs For The Nervous System

*Antiparkinson Anticholinergics*** - Drugs For Parkinson

benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg 1

trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1

*Antiparkinson Dopaminergics*** - Drugs For Parkinson

amantadine hcl oral capsule 100 mg 1

amantadine hcl oral syrup 50 mg/5ml 1

amantadine hcl oral tablet 100 mg 1

bromocriptine mesylate oral capsule 5 mg 1

bromocriptine mesylate oral tablet 2.5 mg 1

Inbrija Inhalation Capsule 42 MG 3 QL

Osmolex ER Oral Tablet Extended Release 24 Hour 129 MG, 193 MG, 258 MG

3 QL

*Antiparkinson Monoamine Oxidase Inhibitors*** - Drugs For Parkinson

rasagiline mesylate oral tablet 0.5 mg, 1 mg 1 QL

selegiline hcl oral capsule 5 mg 1

selegiline hcl oral tablet 5 mg 1

Xadago Oral Tablet 100 MG, 50 MG 3 QL

Zelapar Oral Tablet Dispersible 1.25 MG 3

*Central/Peripheral Comt Inhibitors*** - Drugs For Parkinson

tolcapone oral tablet 100 mg 1 QL


48


*Decarboxylase Inhibitors*** - Drugs For Parkinson

carbidopa oral tablet 25 mg 1

*Levodopa Combinations*** - Drugs For Parkinson

carbidopa-levodopa er oral tablet extended release25-100 mg, 50-200 mg

1

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

1

carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg, 25-250 mg

1

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

1

Rytary Oral Capsule Extended Release 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG

3

*Nonergoline Dopamine Receptor Agonists*** - Drugs For Parkinson

Neupro Transdermal Patch 24 Hour 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR

3

pramipexole dihydrochloride er oral tablet extended release 24 hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

1 QL

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

1 QL

ropinirole hcl er oral tablet extended release 24 hour12 mg, 2 mg, 4 mg, 6 mg, 8 mg

1 QL

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

1

*Peripheral Comt Inhibitors*** - Drugs For Parkinson

entacapone oral tablet 200 mg 1

*Antipsychotics/Antimanic Agents* - Drugs For The Nervous System

*Antimanic Agents*** - Drugs For Severe Mental Disorders

lithium carbonate er oral tablet extended release 300 mg, 450 mg

1 Age Restriction Applies (Min 5 Years)

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg


lithium carbonate oral tablet 300 mg 1 Age Restriction Applies (Min 5 Years)

lithium oral solution 8 meq/5ml 2 Age Restriction Applies (Min 5 Years)

Lithobid Oral Tablet Extended Release 300 MG 3 Age Restriction Applies (Min 5 Years)

*Antipsychotics - Misc.*** - Drugs For Severe Mental Disorders

Equetro Oral Capsule Extended Release 12 Hour100 MG, 200 MG, 300 MG



49


Latuda Oral Tablet 120 MG, 20 MG, 40 MG, 60 MG, 80 MG


Nuplazid Oral Capsule 34 MG 3QL; Age Restriction Applies (Min 5 Years)

Nuplazid Oral Tablet 10 MG 3QL; Age Restriction Applies (Min 5 Years)

Vraylar Oral Capsule 1.5 MG, 3 MG, 4.5 MG, 6 MG 3QL; Age Restriction Applies (Min 5 Years)

Vraylar Oral Capsule Therapy Pack 1.5 & 3 MG 3 QL

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg


*Benzisoxazoles*** - Drugs For Severe Mental Disorders

Fanapt Oral Tablet 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG


Fanapt Titration Pack Oral Tablet 1 & 2 & 4 & 6 MG 3QL; Age Restriction Applies (Min 5 Years)

paliperidone er oral tablet extended release 24 hour1.5 mg, 3 mg, 6 mg, 9 mg


risperidone oral solution 1 mg/ml 1QL; Age Restriction Applies (Min 5 Years)

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg


risperidone oral tablet 4 mg 1QL; Age Restriction Applies (Min 5 Years)

risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg


*Butyrophenones*** - Drugs For Severe Mental Disorders

haloperidol lactate oral concentrate 2 mg/ml 1 Age Restriction Applies (Min 5 Years)

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg


*Dibenzodiazepines*** - Drugs For Severe Mental Disorders

clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1QL; Age Restriction Applies (Min 5 Years)

clozapine oral tablet dispersible 100 mg, 12.5 mg, 25 mg


Versacloz Oral Suspension 50 MG/ML 3 Age Restriction Applies (Min 5 Years)

*Dibenzo-Oxepino Pyrroles*** - Drugs For Severe Mental Disorders

Saphris Sublingual Tablet Sublingual 10 MG, 2.5 MG, 5 MG


*Dibenzothiazepines*** - Drugs For Severe Mental Disorders

quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg, 300 mg, 400 mg, 50 mg



50


quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg


*Dibenzoxazepines*** - Drugs For Severe Mental Disorders

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg


*Phenothiazines*** - Drugs For Severe Mental Disorders

chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg


Compro Rectal Suppository 25 MG 1 Age Restriction Applies (Min 5 Years)

fluphenazine hcl oral concentrate 5 mg/ml 1 Age Restriction Applies (Min 5 Years)

fluphenazine hcl oral elixir 2.5 mg/5ml 1 Age Restriction Applies (Min 5 Years)

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg 1 Age Restriction Applies (Min 5 Years)

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1 Age Restriction Applies (Min 5 Years)

prochlorperazine maleate oral tablet 10 mg, 5 mg 1 Age Restriction Applies (Min 5 Years)

prochlorperazine rectal suppository 25 mg 1 Age Restriction Applies (Min 5 Years)

thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg


trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg 1 Age Restriction Applies (Min 5 Years)

*Quinolinone Derivatives*** - Drugs For Severe Mental Disorders

aripiprazole oral solution 1 mg/ml 1QL; Age Restriction Applies (Min 5 Years)

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg


aripiprazole oral tablet dispersible 10 mg, 15 mg 1QL; Age Restriction Applies (Min 5 Years)

Rexulti Oral Tablet 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG


*Thienbenzodiazepines*** - Drugs For Severe Mental Disorders

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg


olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg


*Thioxanthenes*** - Drugs For Severe Mental Disorders

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 Age Restriction Applies (Min 5 Years)

*Antiretrovirals Adjuvants*** - Drugs That Alter Metabolism

*Antiretrovirals Adjuvants*** - Drugs That Alter Metabolism

Tybost Oral Tablet 150 MG 3 QL


51


*Antisense Oligonucleotide (Aso) Inhibitor Agents*** - Hormones

*Antisense Oligonucleotide (Aso) Inhibitor Agents*** - Hormones

Tegsedi Subcutaneous Solution Prefilled Syringe284 MG/1.5ML

3 PA

*Antiseptics & Disinfectants* - Antiseptics And Disinfectants

*Antiseptics & Disinfectants*** - Antiseptics And Disinfectants

formaldehyde external solution 10 % 1

formaldehyde external solution 37 % 3

glutaraldehyde external solution 25 % 2

Kerr Triple Dye Swabs External Swab 3

phenol external liquid 2

*Chlorine Antiseptics*** - Antiseptics And Disinfectants

benzalkonium chloride external concentrate 50 % 2

benzalkonium chloride external solution , 50 % 2

chlorhexidine gluconate solution 20 % 2

*Iodine Antiseptics*** - Antiseptics And Disinfectants

iodine tincture external tincture 2 % 3

*Antivirals* - Drugs For Infections

*Antiretroviral Combinations*** - Drugs For Viral Infections

abacavir sulfate-lamivudine oral tablet 600-300 mg 1

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg

1

Atripla Oral Tablet 600-200-300 MG 2

Biktarvy Oral Tablet 50-200-25 MG 3 QL

Cimduo Oral Tablet 300-300 MG 3 QL

Combivir Oral Tablet 150-300 MG 3

Complera Oral Tablet 200-25-300 MG 2 QL

Delstrigo Oral Tablet 100-300-300 MG 3 QL

Descovy Oral Tablet 200-25 MG 3 QL

Dovato Oral Tablet 50-300 MG 3

Epzicom Oral Tablet 600-300 MG 3

Evotaz Oral Tablet 300-150 MG 2 QL

Genvoya Oral Tablet 150-150-200-10 MG 3

Juluca Oral Tablet 50-25 MG 2 QL

Kaletra Oral Solution 400-100 MG/5ML 3

Kaletra Oral Tablet 100-25 MG, 200-50 MG 2

lamivudine-zidovudine oral tablet 150-300 mg 1


52


lopinavir-ritonavir oral solution 400-100 mg/5ml 1

Odefsey Oral Tablet 200-25-25 MG 2 QL

Prezcobix Oral Tablet 800-150 MG 2 QL

Stribild Oral Tablet 150-150-200-300 MG 2 QL

Symfi Lo Oral Tablet 400-300-300 MG 3 QL

Symfi Oral Tablet 600-300-300 MG 3 QL

Symtuza Oral Tablet 800-150-200-10 MG 3 QL

Triumeq Oral Tablet 600-50-300 MG 3 QL

Trizivir Oral Tablet 300-150-300 MG 3

Truvada Oral Tablet 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG

2

*Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** - Drugs For Viral Infections

Selzentry Oral Solution 20 MG/ML 3 QL

Selzentry Oral Tablet 150 MG, 25 MG, 300 MG, 75 MG

3 QL

*Antiretrovirals - Fusion Inhibitors*** - Drugs For Viral Infections

Fuzeon Subcutaneous Solution Reconstituted 90 MG

3 QL

*Antiretrovirals - Integrase Inhibitors*** - Drugs For Viral Infections

Isentress HD Oral Tablet 600 MG 2 QL

Isentress Oral Packet 100 MG 2 QL

Isentress Oral Tablet 400 MG 2 QL

Isentress Oral Tablet Chewable 100 MG, 25 MG 2 QL

Tivicay Oral Tablet 10 MG, 25 MG, 50 MG 2 QL

*Antiretrovirals - Protease Inhibitors*** - Drugs For Viral Infections

Aptivus Oral Capsule 250 MG 3

Aptivus Oral Solution 100 MG/ML 3

atazanavir sulfate oral capsule 150 mg, 200 mg, 300 mg

1

Crixivan Oral Capsule 200 MG, 400 MG 3

fosamprenavir calcium oral tablet 700 mg 1

Invirase Oral Tablet 500 MG 3

Lexiva Oral Suspension 50 MG/ML 2

Lexiva Oral Tablet 700 MG 2

Norvir Oral Packet 100 MG 3

Norvir Oral Solution 80 MG/ML 2

Norvir Oral Tablet 100 MG 3

Prezista Oral Suspension 100 MG/ML 2

Prezista Oral Tablet 150 MG, 600 MG, 75 MG, 800 MG

2 QL


53


Reyataz Oral Capsule 150 MG, 200 MG, 300 MG 3

Reyataz Oral Packet 50 MG 2

ritonavir oral tablet 100 mg 1

Viracept Oral Tablet 250 MG, 625 MG 3

*Antiretrovirals - Rti-Non-Nucleoside Analogues*** - Drugs For Viral Infections

Edurant Oral Tablet 25 MG 3 QL

efavirenz oral capsule 200 mg, 50 mg 1

efavirenz oral tablet 600 mg 1

Intelence Oral Tablet 100 MG, 200 MG, 25 MG 3 QL

nevirapine er oral tablet extended release 24 hour 100 mg, 400 mg

1 QL

nevirapine oral tablet 200 mg 1

Pifeltro Oral Tablet 100 MG 3 QL

Sustiva Oral Capsule 200 MG, 50 MG 3

Sustiva Oral Tablet 600 MG 3

Viramune Oral Suspension 50 MG/5ML 3

Viramune Oral Tablet 200 MG 3

Viramune XR Oral Tablet Extended Release 24 Hour 400 MG

3 QL

*Antiretrovirals - Rti-Nucleoside Analogues-Purines*** - Drugs For Viral Infections

abacavir sulfate oral solution 20 mg/ml 1

abacavir sulfate oral tablet 300 mg 1

didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg

1

Ziagen Oral Solution 20 MG/ML 3

Ziagen Oral Tablet 300 MG 3

*Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines*** - Drugs For Viral Infections

Emtriva Oral Capsule 200 MG 3 QL

Emtriva Oral Solution 10 MG/ML 3 QL

Epivir Oral Solution 10 MG/ML 3

Epivir Oral Tablet 150 MG, 300 MG 3

lamivudine oral solution 10 mg/ml 1

lamivudine oral tablet 150 mg, 300 mg 1

*Antiretrovirals - Rti-Nucleoside Analogues-Thymidines*** - Drugs For Viral Infections

Retrovir Oral Capsule 100 MG 3

Retrovir Oral Syrup 50 MG/5ML 3

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg 1

zidovudine oral capsule 100 mg 1

zidovudine oral syrup 50 mg/5ml 1

zidovudine oral tablet 300 mg 1


54


*Antiretrovirals - Rti-Nucleotide Analogues*** - Drugs For Viral Infections

tenofovir disoproxil fumarate oral tablet 300 mg 1

Viread Oral Powder 40 MG/GM 2

Viread Oral Tablet 150 MG, 200 MG, 250 MG 2

Viread Oral Tablet 300 MG 3

*Cmv Agents*** - Drugs For Viral Infections

Prevymis Oral Tablet 240 MG, 480 MG 3 QL

Valcyte Oral Solution Reconstituted 50 MG/ML 3

Valcyte Oral Tablet 450 MG 3

valganciclovir hcl oral solution reconstituted 50 mg/ml 1

valganciclovir hcl oral tablet 450 mg 1

*Hepatitis B Agents*** - Drugs For Viral Infections

adefovir dipivoxil oral tablet 10 mg 1

Baraclude Oral Solution 0.05 MG/ML 3

Baraclude Oral Tablet 0.5 MG, 1 MG 3

entecavir oral tablet 0.5 mg, 1 mg 1

Epivir HBV Oral Solution 5 MG/ML 2

Epivir HBV Oral Tablet 100 MG 3

Hepsera Oral Tablet 10 MG 3

lamivudine oral tablet 100 mg 1

Vemlidy Oral Tablet 25 MG 2

*Hepatitis C Agents*** - Drugs For Viral Infections

Pegasys ProClick Subcutaneous Solution 180 MCG/0.5ML

2 QL

Pegasys Subcutaneous Solution 180 MCG/0.5ML, 180 MCG/ML

2 QL

PegIntron Subcutaneous Kit 50 MCG/0.5ML 2 QL

ribavirin oral capsule 200 mg 1

ribavirin oral tablet 200 mg 1

*Herpes Agents - Purine Analogues*** - Drugs For Viral Infections

acyclovir oral capsule 200 mg 1

acyclovir oral suspension 200 mg/5ml 1

acyclovir oral tablet 400 mg, 800 mg 1

Sitavig Buccal Tablet 50 MG 3

valacyclovir hcl oral tablet 1 gm, 500 mg 1

*Herpes Agents - Thymidine Analogues*** - Drugs For Viral Infections

famciclovir oral tablet 125 mg, 250 mg, 500 mg 1

*Influenza Agents*** - Drugs For Viral Infections

rimantadine hcl oral tablet 100 mg 1


55


*Neuraminidase Inhibitors*** - Drugs For Viral Infections

oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg

1 QL

oseltamivir phosphate oral suspension reconstituted 6 mg/ml

1 QL

Relenza Diskhaler Inhalation Aerosol Powder Breath Activated 5 MG/BLISTER

3 QL

Tamiflu Oral Capsule 30 MG, 45 MG, 75 MG 3 QL

Tamiflu Oral Suspension Reconstituted 6 MG/ML 3 QL

*Anti-Von Willebrand Factor Agents*** - Drugs For The Blood

*Anti-Von Willebrand Factor Agents*** - Drugs For The Blood

Cablivi Injection Kit 11 MG 3 PA

*Assorted Classes* - Vitamins And Minerals

*Antileprotics*** - Vitamins And Minerals

Thalomid Oral Capsule 100 MG, 150 MG, 200 MG, 50 MG

3 PA; QL

*B-Lymphocyte Stimulator (Blys)-Specific Inhibitors*** - Vitamins And Minerals

Benlysta Intravenous Solution Reconstituted 120 MG, 400 MG

3 PA; QL

Benlysta Subcutaneous Solution Auto-Injector 200 MG/ML

3 PA; QL

Benlysta Subcutaneous Solution Prefilled Syringe200 MG/ML

3 PA; QL

*Chelating Agents*** - Vitamins And Minerals

penicillamine oral capsule 250 mg 1

penicillamine oral tablet 250 mg 1

Syprine Oral Capsule 250 MG 3

trientine hcl oral capsule 250 mg 1

*Cyclosporine Analogs*** - Vitamins And Minerals

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg

1

cyclosporine modified oral solution 100 mg/ml 1

cyclosporine oral capsule 100 mg, 25 mg 1

Gengraf Oral Capsule 100 MG, 25 MG 1

Gengraf Oral Solution 100 MG/ML 1

Neoral Oral Capsule 100 MG, 25 MG 3

Neoral Oral Solution 100 MG/ML 3

SandIMMUNE Oral Capsule 100 MG, 25 MG 3

SandIMMUNE Oral Solution 100 MG/ML 3


56


*Immunomodulators For Myelodysplastic Syndromes*** - Vitamins And Minerals

Revlimid Oral Capsule 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG

2 PA; QL

*Inosine Monophosphate Dehydrogenase Inhibitors*** - Vitamins And Minerals

mycophenolate mofetil oral capsule 250 mg 1

mycophenolate mofetil oral suspension reconstituted200 mg/ml

1

mycophenolate mofetil oral tablet 500 mg 1

mycophenolate sodium oral tablet delayed release180 mg, 360 mg

1

*Macrolide Immunosuppressants*** - Vitamins And Minerals

Astagraf XL Oral Capsule Extended Release 24 Hour 0.5 MG, 1 MG, 5 MG

3

Envarsus XR Oral Tablet Extended Release 24 Hour 0.75 MG, 1 MG, 4 MG

3

Prograf Oral Capsule 0.5 MG, 1 MG, 5 MG 3

Prograf Oral Packet 0.2 MG, 1 MG 3Age Restriction Applies (Max 12 Years)

Rapamune Oral Solution 1 MG/ML 3

sirolimus oral solution 1 mg/ml 1

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 1

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 1

Zortress Oral Tablet 0.25 MG, 0.5 MG, 0.75 MG, 1 MG

3

*Potassium Removing Resins*** - Vitamins And Minerals

Kionex Oral Suspension 15 GM/60ML 1

Lokelma Oral Packet 10 GM, 5 GM 3

sodium polystyrene sulfonate oral powder 1

sodium polystyrene sulfonate oral suspension 15 gm/60ml

1

sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 gm/200ml

1

SPS Oral Suspension 15 GM/60ML 1

Veltassa Oral Packet 16.8 GM, 25.2 GM, 8.4 GM 3

*Purine Analogs*** - Vitamins And Minerals

Azasan Oral Tablet 100 MG, 75 MG 1

azathioprine oral tablet 50 mg 1


57


*Atopic Dermatitis - Monoclonal Antibodies*** - Drugs For The Lungs

*Atopic Dermatitis - Monoclonal Antibodies*** - Drugs For The Lungs

Dupixent Subcutaneous Solution Prefilled Syringe200 MG/1.14ML, 300 MG/2ML

3 PA

*Beta Blockers* - Drugs For The Heart

*Alpha-Beta Blockers*** - Drugs For High Blood Pressure

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

1

carvedilol phosphate er oral capsule extended release 24 hour 10 mg, 20 mg, 40 mg, 80 mg

1 QL

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1

*Beta Blockers Cardio-Selective*** - Drugs For High Blood Pressure

acebutolol hcl oral capsule 200 mg, 400 mg 1

atenolol oral tablet 100 mg, 25 mg, 50 mg 1

betaxolol hcl oral tablet 10 mg, 20 mg 1

bisoprolol fumarate oral tablet 10 mg, 5 mg 1

Bystolic Oral Tablet 10 MG, 2.5 MG, 20 MG, 5 MG 2 QL

metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg

1

metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

1

Tenormin Oral Tablet 100 MG, 50 MG 3

*Beta Blockers Non-Selective*** - Drugs For High Blood Pressure

Hemangeol Oral Solution 4.28 MG/ML 3

Inderal XL Oral Capsule Extended Release 24 Hour120 MG, 80 MG

3

nadolol oral tablet 20 mg, 40 mg, 80 mg 1

pindolol oral tablet 10 mg, 5 mg 1

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

1

propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

1

Sorine Oral Tablet 120 MG, 160 MG, 240 MG, 80 MG

1

sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1

sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1

Sotylize Oral Solution 5 MG/ML 3

timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1


58


*Bile Acid Synthesis Disorder Agents*** - Drugs For The Stomach

*Bile Acid Synthesis Disorder Agents*** - Drugs For The Stomach

Cholbam Oral Capsule 250 MG, 50 MG 3 PA

*Biologicals Misc* - Biological Agents

*Allergenic Extracts*** - Biological Agents

Grastek Sublingual Tablet Sublingual 2800 BAU 3QL; Age Restriction Applies (Min 5 Years and Max 65 Years)

Palforzia (12 MG Daily Dose) Oral 2 x 1 MG & 10 MG

3Age Restriction Applies (Min 4 Years and Max 17 Years)

Palforzia (120 MG Daily Dose) Oral 20 MG & 100 MG


Palforzia (160 MG Daily Dose) Oral 3 x 20 MG & 100 MG


Palforzia (20 MG Daily Dose) Oral 20 MG 3Age Restriction Applies (Min 4 Years and Max 17 Years)

Palforzia (200 MG Daily Dose) Oral 2 x 100 MG 3Age Restriction Applies (Min 4 Years and Max 17 Years)

Palforzia (240 MG Daily Dose) Oral 2 x 20 MG & 2 x 100 MG



Palforzia (300 MG Maintenance) Oral Packet 300 MG


Palforzia (300 MG Titration) Oral Packet 300 MG 3Age Restriction Applies (Min 4 Years and Max 17 Years)




Palforzia Initial Escalation Oral 0.5 & 1 & 1.5 & 3 & 6 MG


Ragwitek Sublingual Tablet Sublingual 12 AMB A 1-U

3QL; Age Restriction Applies (Min 18 Years and Max 65 Years)

*Calcitonin Gene-Related Peptide (Cgrp) Receptor Antag*** - Drugs For The Nervous System

*Calcitonin Gene-Related Peptide (Cgrp) Receptor Antag*** - Drugs For The Nervous System

Aimovig Subcutaneous Solution Auto-Injector 140 MG/ML, 70 MG/ML

2 PA

Ajovy Subcutaneous Solution Auto-Injector 225 MG/1.5ML

2 PA

Ajovy Subcutaneous Solution Prefilled Syringe225 MG/1.5ML

2 PA


59


Emgality (300 MG Dose) Subcutaneous Solution Prefilled Syringe 100 MG/ML

2 PA

Emgality Subcutaneous Solution Auto-Injector 120 MG/ML

2 PA

Emgality Subcutaneous Solution Prefilled Syringe120 MG/ML

2 PA

*Calcitonin Gene-Related Peptide Receptor Antag (Cgrp)*** - Drugs For The Nervous System

*Calcitonin Gene-Related Peptide Receptor Antag (Cgrp)*** - Drugs For The Nervous System

Ubrelvy Oral Tablet 100 MG, 50 MG 3 PA; QL

*Calcium Channel Blockers* - Drugs For The Heart

*Calcium Channel Blockers*** - Drugs For High Blood Pressure

amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1

Cardizem LA Oral Tablet Extended Release 24 Hour 120 MG

3

Cartia XT Oral Capsule Extended Release 24 Hour120 MG, 180 MG, 240 MG, 300 MG

1

diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

1

diltiazem hcl er coated beads oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1

diltiazem hcl er oral capsule extended release 12 hour120 mg, 60 mg, 90 mg

1

diltiazem hcl er oral capsule extended release 24 hour120 mg

1

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1

dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

1

felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg

1

isradipine oral capsule 2.5 mg, 5 mg 1

Katerzia Oral Suspension 1 MG/ML 3Age Restriction Applies (Max 11 Years)

Matzim LA Oral Tablet Extended Release 24 Hour180 MG, 240 MG, 300 MG, 360 MG, 420 MG

1

nicardipine hcl oral capsule 20 mg, 30 mg 1

nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

1

nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

1

nifedipine oral capsule 10 mg, 20 mg 1


60


nimodipine oral capsule 30 mg 1

nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg

1

Taztia XT Oral Capsule Extended Release 24 Hour120 MG, 180 MG, 240 MG, 300 MG, 360 MG

1

verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg

1

verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg

1

verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1

*Cardiotonics* - Drugs For The Heart

*Cardiac Glycosides*** - Drugs For The Heart

Digitek Oral Tablet 125 MCG, 250 MCG 1

Digox Oral Tablet 125 MCG, 250 MCG 1

digoxin oral solution 0.05 mg/ml 1

digoxin oral tablet 125 mcg, 250 mcg 1

Lanoxin Oral Tablet 125 MCG, 250 MCG, 62.5 MCG 3

*Cardiovascular Agents - Misc.* - Drugs For The Heart

*Calcium Channel Blocker & Hmg Coa Reductase Inhibit Comb*** - Drugs For Cholesterol

amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg

1

*Nitrate & Vasodilator Combinations*** - Drugs For High Blood Pressure

BiDil Oral Tablet 20-37.5 MG 3

*Peripheral Vasodilators*** - Drugs For High Blood Pressure

isoxsuprine hcl oral tablet 10 mg, 20 mg 1

*Prostaglandin - Impotence Agents*** - Drugs For High Blood Pressure

Caverject Impulse Intracavernosal Kit 10 MCG, 20 MCG

3 Male Only; QL

Caverject Intracavernosal Solution Reconstituted40 MCG

3 Male Only; QL

Edex Intracavernosal Kit 10 MCG, 20 MCG, 40 MCG

3 Male Only; QL

Muse Urethral Pellet 1000 MCG, 125 MCG, 250 MCG, 500 MCG

3 Male Only; QL

*Prostaglandin Vasodilators*** - Drugs For High Blood Pressure

Orenitram Oral Tablet Extended Release 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG

2 PA; QL

Tyvaso Inhalation Solution 0.6 MG/ML 3 PA

Tyvaso Refill Inhalation Solution 0.6 MG/ML 3 PA


61


Tyvaso Starter Inhalation Solution 0.6 MG/ML 3 PA

Ventavis Inhalation Solution 10 MCG/ML, 20 MCG/ML

2 PA

*Pulm Hyperten-Soluble Guanylate Cyclase Stimulator (Sgc)*** - Drugs For High Blood Pressure

Adempas Oral Tablet 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG

3 PA; QL

*Pulmonary Hypertension - Endothelin Receptor Antagonists*** - Drugs For High Blood Pressure

ambrisentan oral tablet 10 mg, 5 mg 1 PA; QL

bosentan oral tablet 125 mg, 62.5 mg 1 PA; QL

Letairis Oral Tablet 10 MG, 5 MG 2 PA; QL

Opsumit Oral Tablet 10 MG 3 PA; QL

Tracleer Oral Tablet 125 MG, 62.5 MG 2 PA; QL

Tracleer Oral Tablet Soluble 32 MG 2 PA; QL

*Pulmonary Hypertension - Phosphodiesterase Inhibitors*** - Drugs For High Blood Pressure

Adcirca Oral Tablet 20 MG 3 PA; QL

Alyq Oral Tablet 20 MG 1 PA; QL

Revatio Oral Suspension Reconstituted 10 MG/ML 2Age Restriction Applies (Max 12 Years)

sildenafil citrate oral suspension reconstituted 10 mg/ml

1

sildenafil citrate oral tablet 20 mg 1 QL

tadalafil (pah) oral tablet 20 mg 1 PA; QL

*Selective Cgmp Phosphodiesterase Type 5 Inhibitors*** - Drugs For High Blood Pressure

Levitra Oral Tablet 10 MG, 20 MG 3 Male Only; QL

sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg 1 Male Only; QL

Stendra Oral Tablet 100 MG, 200 MG, 50 MG 3 Male Only

tadalafil oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 Male Only; QL

vardenafil hcl oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 Male Only; QL

vardenafil hcl oral tablet dispersible 10 mg 1 Male Only; QL

*Cephalosporins* - Drugs For Infections

*Cephalosporins - 1St Generation*** - Antibiotics

cefadroxil oral capsule 500 mg 1

cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml

1

cefadroxil oral tablet 1 gm 1

cephalexin oral capsule 250 mg, 500 mg, 750 mg 1

cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

cephalexin oral tablet 250 mg, 500 mg 1


62


*Cephalosporins - 2Nd Generation*** - Antibiotics

cefaclor er oral tablet extended release 12 hour 500 mg

1

cefaclor oral capsule 250 mg, 500 mg 1

cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml

1

cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

cefprozil oral tablet 250 mg, 500 mg 1

cefuroxime axetil oral tablet 250 mg, 500 mg 1

*Cephalosporins - 3Rd Generation*** - Antibiotics

cefdinir oral capsule 300 mg 1

cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

cefditoren pivoxil oral tablet 200 mg 1

cefixime oral capsule 400 mg 1

cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

1

cefpodoxime proxetil oral suspension reconstituted100 mg/5ml, 50 mg/5ml

1

cefpodoxime proxetil oral tablet 100 mg, 200 mg 1

Suprax Oral Suspension Reconstituted 100 MG/5ML, 200 MG/5ML, 500 MG/5ML

3

Suprax Oral Tablet Chewable 100 MG, 200 MG 3

*Cgrp Receptor Antagonists - Monocolonal Antibodies*** - Drugs For The Nervous System

*Cgrp Receptor Antagonists - Monocolonal Antibodies*** - Drugs For The Nervous System

Aimovig Subcutaneous Solution Auto-Injector 140 MG/ML, 70 MG/ML

2 PA

Ajovy Subcutaneous Solution Auto-Injector 225 MG/1.5ML

2 PA

Ajovy Subcutaneous Solution Prefilled Syringe225 MG/1.5ML

2 PA

Emgality (300 MG Dose) Subcutaneous Solution Prefilled Syringe 100 MG/ML

2 PA

Emgality Subcutaneous Solution Auto-Injector 120 MG/ML

2 PA

Emgality Subcutaneous Solution Prefilled Syringe120 MG/ML

2 PA

*Chemicals*

*Bulk Chemicals - Le's***

calcium folinate powder 2

leucovorin calcium powder 2

*Bulk Chemicals - Py's***

pyrimethamine powder 2


63


*Fixed Oils***

almond oil (sweet) oil 2

base g almond oil (sweet) oil 2

castor oil oil 2

coconut oil oil 2

cottonseed oil oil 2

hm castor oil oil 2

linseed oil oil 2

olive oil oil 2

organic coconut oil oil 2

peanut oil oil 2

qc castor oil oil 2

qc sweet oil oil 2

safflower oil oil 2

sesame oil oil 2

sm sweet oil oil 2

soybean oil oil 2

sweet oil oil 2

*Liquids***

benzyl benzoate liquid 2

*Cic Agents - Guanylate Cyclase-C (Gc-C) Agonists*** - Drugs For The Stomach

*Cic Agents - Guanylate Cyclase-C (Gc-C) Agonists*** - Drugs For The Stomach

Trulance Oral Tablet 3 MG 3 QL

*Contraceptives* - Drugs For Women

*Biphasic Contraceptives - Oral*** - Birth Control Pills

Azurette Oral Tablet 0.15-0.02/0.01 MG (21/5) 1

Bekyree Oral Tablet 0.15-0.02/0.01 MG (21/5) 1

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)

1

Kariva Oral Tablet 0.15-0.02/0.01 MG (21/5) 1

Lo Loestrin Fe Oral Tablet 1 MG-10 MCG / 10 MCG 2 ST

Pimtrea Oral Tablet 0.15-0.02/0.01 MG (21/5) 1

viorele oral tablet 0.15-0.02/0.01 mg (21/5) 1

*Combination Contraceptives - Oral*** - Birth Control Pills

Balcoltra Oral Tablet 0.1-20 MG-MCG(21) 3 ST

drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg

1

FaLessa Oral Kit 20-1-0.1 MCG-MG 2 ST

Kaitlib Fe Oral Tablet Chewable 0.8-25 MG-MCG 1


64


Layolis FE Oral Tablet Chewable 0.8-25 MG-MCG 1

norethin-eth estradiol-fe oral tablet chewable 0.8-25 mg-mcg

1

Taytulla Oral Capsule 1-20 MG-MCG(24) 2 ST

*Combination Contraceptives - Vaginal*** - Birth Control Pills

Annovera Vaginal Ring 0.013-0.15 MG/24HR 3 Female Only; QL

NuvaRing Vaginal Ring 0.12-0.015 MG/24HR 2 QL

*Emergency Contraceptives*** - Birth Control Pills

Ella Oral Tablet 30 MG 2

*Four Phase Contraceptives - Oral*** - Birth Control Pills

Natazia Oral Tablet 3/2-2/2-3/1 MG 2 ST

*Progestin Contraceptives - Oral*** - Birth Control Pills

Slynd Oral Tablet 4 MG 3 ST; Female Only

*Triphasic Contraceptives - Oral*** - Birth Control Pills

Leena Oral Tablet 0.5/1/0.5-35 MG-MCG 3

norgestim-eth estrad triphasic oral tablet0.18/0.215/0.25 mg-25 mcg

1

Tri-Lo-Estarylla Oral Tablet 0.18/0.215/0.25 MG-25 MCG

1

Tri-Lo-Marzia Oral Tablet 0.18/0.215/0.25 MG-25 MCG

1

Tri-Lo-Sprintec Oral Tablet 0.18/0.215/0.25 MG-25 MCG

1

Tri-VyLibra Lo Oral Tablet 0.18/0.215/0.25 MG-25 MCG

1

*Corticosteroids* - Hormones

*Glucocorticosteroids*** - Drugs For Inflammation

budesonide er oral tablet extended release 24 hour 9 mg

1

budesonide oral capsule delayed release particles 3 mg

1

cortisone acetate oral tablet 25 mg 1

Decadron Oral Tablet 0.5 MG, 0.75 MG, 4 MG, 6 MG 1

Dexamethasone Intensol Oral Concentrate 1 MG/ML

1

dexamethasone oral elixir 0.5 mg/5ml 1

dexamethasone oral solution 0.5 mg/5ml 1

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

1

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1

Medrol Oral Tablet 2 MG 3


65


methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

1

methylprednisolone oral tablet therapy pack 4 mg 1

Millipred DP 12-Day Oral Tablet Therapy Pack 5 MG (48)

1

Millipred DP Oral Tablet Therapy Pack 5 MG (21), 5 MG (48)

1

Millipred Oral Tablet 5 MG 1

prednisolone oral solution 15 mg/5ml 1

prednisolone sodium phosphate oral solution 10 mg/5ml, 15 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

1

prednisolone sodium phosphate oral tablet dispersible10 mg, 15 mg, 30 mg

1

PredniSONE Intensol Oral Concentrate 5 MG/ML 1

prednisone oral solution 5 mg/5ml 1

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

1

prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48)

1

Rayos Oral Tablet Delayed Release 1 MG, 2 MG, 5 MG

3

*Mineralocorticoids*** - Drugs For Inflammation

fludrocortisone acetate oral tablet 0.1 mg 1

*Cortisol Synthesis Inhibitors*** - Hormones

*Cortisol Synthesis Inhibitors*** - Hormones

Isturisa Oral Tablet 1 MG, 10 MG, 5 MG 3 PA

*Cough/Cold/Allergy* - Drugs For The Lungs

*Antitussive - Nonnarcotic*** - Drugs For Allergies

benzonatate oral capsule 100 mg, 150 mg, 200 mg 1

*Antitussive - Opioid*** - Drugs For Cough And Cold

hydrocodone-homatropine oral syrup 5-1.5 mg/5ml 1

hydrocodone-homatropine oral tablet 5-1.5 mg 1

hydromet oral syrup 5-1.5 mg/5ml 1

*Antitussive-Expectorant*** - Drugs For Cough And Cold

cheratussin ac oral syrup 100-10 mg/5ml 1Age Restriction Applies (Min 12 Years)

g tussin ac oral solution 100-10 mg/5ml 1Age Restriction Applies (Min 12 Years)

guaiatussin ac oral syrup 100-10 mg/5ml 1Age Restriction Applies (Min 12 Years)

guaifenesin ac oral syrup 100-10 mg/5ml 1Age Restriction Applies (Min 12 Years)


66


guaifenesin-codeine oral solution 100-10 mg/5ml 1Age Restriction Applies (Min 12 Years)

virtussin a/c oral solution 100-10 mg/5ml 1Age Restriction Applies (Min 12 Years)

*Antitussive-Expectorants-Decongestant*** - Drugs For Cough And Cold

Actinel Pediatric Oral Liquid 15-5-50 MG/5ML 3

guaifenesin dac oral solution 30-10-100 mg/5ml 1

Tusnel Pediatric Oral Liquid 15-5-50 MG/5ML 3

virtussin dac oral solution 30-10-100 mg/5ml 1

*Decongestant & Antihistamine*** - Drugs For Cough And Cold

promethazine-phenylephrine oral syrup 6.25-5 mg/5ml 1

Semprex-D Oral Capsule 8-60 MG 3

*Iodine Expectorants*** - Drugs For Cough And Cold

SSKI Oral Solution 1 GM/ML 2

*Misc. Respiratory Inhalants*** - Drugs For Allergies

HyperSal Inhalation Nebulization Solution 3.5 % 3

Nebusal Inhalation Nebulization Solution 3 % 1

Nebusal Inhalation Nebulization Solution 6 % 3

PulmoSal Inhalation Nebulization Solution 7 % 1

sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 %, 7 %

1

*Mucolytics*** - Drugs For The Lungs

acetylcysteine inhalation solution 10 %, 20 % 1

*Non-Narc Antitussive-Antihistamine*** - Drugs For Cough And Cold

promethazine-dm oral syrup 6.25-15 mg/5ml 1

*Non-Narc Antitussive-Decongestant-Antihistamine*** - Drugs For Cough And Cold

Bromfed DM Oral Syrup 30-2-10 MG/5ML 1

pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml 1

*Opioid Antitussive-Antihistamine*** - Drugs For Cough And Cold

hydrocod polst-cpm polst er oral suspension extended release 10-8 mg/5ml

1

promethazine-codeine oral solution 6.25-10 mg/5ml 1Age Restriction Applies (Min 12 Years)

promethazine-codeine oral syrup 6.25-10 mg/5ml 1Age Restriction Applies (Min 12 Years)

TussiCaps Oral Capsule Extended Release 12 Hour 10-8 MG

3

Tuzistra XR Oral Suspension Extended Release14.7-2.8 MG/5ML



67


Z-Tuss AC Oral Liquid 2-9 MG/5ML 3

*Opioid Antitussive-Decongestant-Antihistamine*** - Drugs For Cough And Cold

Histex-AC Oral Syrup 10-2.5-10 MG/5ML 2

promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml


Pro-Red AC Oral Syrup 5-1-9 MG/5ML 3

*Cyclin-Dependent Kinases (Cdk) Inhibitors*** - Drugs For Cancer

*Cyclin-Dependent Kinases (Cdk) Inhibitors*** - Drugs For Cancer

Ibrance Oral Capsule 100 MG, 125 MG, 75 MG 2 PA; QL

Ibrance Oral Tablet 100 MG, 125 MG, 75 MG 2 PA; QL

Kisqali (200 MG Dose) Oral Tablet Therapy Pack200 MG

3 PA


3 PA


3 PA

Verzenio Oral Tablet 100 MG, 150 MG, 200 MG, 50 MG

3 PA

*Cystic Fibrosis Agent - Combinations*** - Drugs For The Lungs

*Cystic Fibrosis Agent - Combinations*** - Drugs For The Lungs

Orkambi Oral Packet 100-125 MG, 150-188 MG 2PA; QL; Age Restriction Applies (Max 5 Years)

Orkambi Oral Tablet 100-125 MG, 200-125 MG 2 PA; QL

Symdeko Oral Tablet Therapy Pack 100-150 & 150 MG, 50-75 & 75 MG

3 PA; QL

Trikafta Oral Tablet Therapy Pack 100-50-75 & 150 MG

3 PA

*Dermatologicals* - Drugs For The Skin

*Acne Antibiotics*** - Drugs For The Skin

Amzeeq External Foam 4 % 3

Clindacin ETZ External Swab 1 % 1

Clindacin-P External Swab 1 % 1

clindamycin phosphate external foam 1 % 1

clindamycin phosphate external gel 1 % 1

clindamycin phosphate external lotion 1 % 1

clindamycin phosphate external solution 1 % 1

clindamycin phosphate external swab 1 % 1

dapsone external gel 5 %, 7.5 % 1

ery external pad 2 % 1

erythromycin external gel 2 % 1


68


erythromycin external solution 2 % 1

sulfacetamide sodium (acne) external lotion 10 % 1

*Acne Combinations*** - Drugs For The Skin

adapalene-benzoyl peroxide external gel 0.1-2.5 % 1 QL

Avar Cleanser External Emulsion 10-5 % 1

Avar-e Emollient External Cream 10-5 % 1

Avar-e Green External Cream 10-5 % 1

benzoyl perox-hydrocortisone external lotion 5-0.5 % 1

benzoyl peroxide-erythromycin external gel 5-3 % 1

bp 10-1 external emulsion 10-1 % 1

bp cleansing wash external emulsion 10-4 % 1

clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 %, 1.2-5 %

1

clindamycin-tretinoin external gel 1.2-0.025 % 1 QL

Epiduo Forte External Gel 0.3-2.5 % 3 QL

Neuac External Gel 1.2-5 % 1

Onexton External Gel 1.2-3.75 % 3

Plexion Cleansing Cloth External Pad 9.8-4.8 % 3

sss 10-5 external cream 10-5 % 1

sss 10-5 external foam 10-5 % 1

sulfacetamide sodium-sulfur external cream 10-2 %, 10-5 %, 9.8-4.8 %

1

sulfacetamide sodium-sulfur external emulsion 10-5 % 1

sulfacetamide sodium-sulfur external liquid 10-2 %, 9-4 %, 9-4.5 %, 9.8-4.8 %

1

sulfacetamide sodium-sulfur external lotion 10-5 %, 9.8-4.8 %

1

sulfacetamide sodium-sulfur external pad 10-4 % 1

sulfacetamide sodium-sulfur external suspension 10-5 %, 8-4 %

1

sulfacetamide-sulfur in urea external emulsion 10-5 % 1

SulfaCleanse 8/4 External Suspension 8-4 % 1

sulfamez wash external emulsion 10-1 % 1

Vanoxide-HC External Lotion 5-0.5 % 1

Veltin External Gel 1.2-0.025 % 3

*Acne Products*** - Drugs For The Skin

Absorica LD Oral Capsule 16 MG, 24 MG, 32 MG, 8 MG

3

Absorica Oral Capsule 10 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG

3

adapalene external cream 0.1 % 1

adapalene external gel 0.1 %, 0.3 % 1

Aklief External Cream 0.005 % 3 ST

Altreno External Lotion 0.05 % 3


69


Amnesteem Oral Capsule 10 MG, 20 MG, 40 MG 1

Avita External Cream 0.025 % 1

Avita External Gel 0.025 % 1

Azelex External Cream 20 % 3

BenzePrO Creamy Wash External Liquid 7 % 1

benzepro external 5.8 % 1

benzepro external foam 5.2 %, 9.7 % 1

BenzePrO External Foam 5.3 % 1

benzepro external liquid 6.8 % 1

BenzePrO Foaming Cloths External 6 % 1

BenzePrO Short Contact External Foam 9.8 % 1

benzoyl peroxide external foam 9.8 % 1

benzoyl peroxide external gel 8 % 1

bp wash external liquid 7 % 1

bpo external gel 4 %, 8 % 3

bpo foaming cloths external 6 % 1

Claravis Oral Capsule 10 MG, 20 MG, 30 MG, 40 MG

1

cvs creamy acne face wash external liquid 4 % 1

Fabior External Foam 0.1 % 3

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1

Myorisan Oral Capsule 10 MG, 20 MG, 30 MG, 40 MG

1

PanOxyl Creamy Wash External Liquid 4 % 1

pr benzoyl peroxide external liquid 6.9 % 1

PR Benzoyl Peroxide Wash External Liquid 7 % 1

Retin-A Micro Pump External Gel 0.06 %, 0.08 % 3

tretinoin external cream 0.025 %, 0.05 %, 0.1 % 1

tretinoin external gel 0.01 %, 0.025 %, 0.05 % 1

tretinoin microsphere external gel 0.04 %, 0.1 % 1

tretinoin microsphere pump external gel 0.04 %, 0.1 % 1

Zenatane Oral Capsule 10 MG, 20 MG, 30 MG, 40 MG

1

*Agents For External Genital And Perianal Warts*** - Drugs For The Skin

Veregen External Ointment 15 % 3 QL

*Antibiotic Steroid Combinations - Topical*** - Drugs For The Skin

Cortisporin External Cream 3.5-10000-0.5 3

Cortisporin External Ointment 1 % 3

Neo-Synalar External Cream 0.5-0.025 % 3

*Antibiotics - Topical*** - Drugs For The Skin

Altabax External Ointment 1 % 3 QL


70


Centany External Ointment 2 % 3

gentamicin sulfate external cream 0.1 % 1

gentamicin sulfate external ointment 0.1 % 1

mupirocin calcium external cream 2 % 1

mupirocin external ointment 2 % 1

Xepi External Cream 1 % 3

*Antifungals - Topical Combinations*** - Drugs For The Skin

Ala-Quin External Cream 3-0.5 % 2

clotrimazole-betamethasone external cream 1-0.05 % 1

clotrimazole-betamethasone external lotion 1-0.05 % 1

Dermazene External Cream 1-1 % 1

Exoderm External Lotion 25-1 % 1

hydrocortisone-iodoquinol external cream 1-1 % 1

iodoquimez-hc external cream 1-1.9 % 1

iodoquinol-hydrocortisone-aloe external cream 1-1.9 %

1

nystatin-triamcinolone external cream 100000-0.1 unit/gm-%

1

nystatin-triamcinolone external ointment 100000-0.1 unit/gm-%

1

*Antifungals - Topical*** - Drugs For The Skin

Ciclodan External Solution 8 % 1

ciclopirox external gel 0.77 % 1

ciclopirox external shampoo 1 % 1

ciclopirox external solution 8 % 1

ciclopirox olamine external cream 0.77 % 1

ciclopirox olamine external suspension 0.77 % 1

naftifine hcl external cream 1 %, 2 % 1

Naftin External Gel 2 % 3 ST

Nyamyc External Powder 100000 UNIT/GM 1

nystatin external cream 100000 unit/gm 1

nystatin external ointment 100000 unit/gm 1

nystatin external powder 100000 unit/gm 1

Nystop External Powder 100000 UNIT/GM 1

*Anti-Inflammatory Agents - Topical*** - Drugs For The Skin

diclofenac epolamine transdermal patch 1.3 % 1 QL

diclofenac sodium transdermal gel 1 % 1 QL

diclofenac sodium transdermal solution 1.5 % 1 QL

Flector Transdermal Patch 1.3 % 3 QL

Pennsaid Transdermal Solution 2 % 3 QL


71


*Antineoplastic Alkylating Agents - Topical*** - Drugs For The Skin

Valchlor External Gel 0.016 % 2

*Antineoplastic Antimetabolites - Topical*** - Drugs For The Skin

Fluoroplex External Cream 1 % 2

fluorouracil external cream 0.5 %, 5 % 1

fluorouracil external solution 2 %, 5 % 1

Tolak External Cream 4 % 2

*Antineoplastic Or Premalignant Lesions - Topical Misc.*** - Drugs For The Skin

Picato External Gel 0.015 %, 0.05 % 2 QL

*Antineoplastic Or Premalignant Lesions - Topical Nsaid's*** - Drugs For The Skin

diclofenac sodium transdermal gel 3 % 1 QL

*Antineoplastic Retinoids - Topical*** - Drugs For The Skin

Panretin External Gel 0.1 % 3

*Antipruritics - Topical*** - Drugs For The Skin

doxepin hcl external cream 5 % 1

*Antipsoriatics - Systemic*** - Drugs For The Skin

acitretin oral capsule 10 mg, 17.5 mg, 25 mg 1 QL

Cosentyx (300 MG Dose) Subcutaneous Solution Prefilled Syringe 150 MG/ML

2 PA; QL

Cosentyx Sensoready (300 MG) Subcutaneous Solution Auto-Injector 150 MG/ML

2 PA; QL

Cosentyx Sensoready Pen Subcutaneous Solution Auto-Injector 150 MG/ML

2 PA; QL

Cosentyx Subcutaneous Solution Prefilled Syringe150 MG/ML

2 PA; QL

methoxsalen rapid oral capsule 10 mg 1 PA

Oxsoralen Ultra Oral Capsule 10 MG 3 PA

Skyrizi (150 MG Dose) Subcutaneous Prefilled Syringe Kit 75 MG/0.83ML

2 PA; QL

Soriatane Oral Capsule 10 MG, 25 MG 3 QL

Stelara Subcutaneous Solution 45 MG/0.5ML 2 PA

Stelara Subcutaneous Solution Prefilled Syringe45 MG/0.5ML, 90 MG/ML

2 PA

Tremfya Subcutaneous Solution Pen-Injector 100 MG/ML

2 PA

Tremfya Subcutaneous Solution Prefilled Syringe100 MG/ML

2 PA

*Antipsoriatics*** - Drugs For The Skin

calcipotriene external cream 0.005 % 1 QL

calcipotriene external foam 0.005 % 1


72


calcipotriene external ointment 0.005 % 1 QL

calcipotriene external solution 0.005 % 1 QL

Calcitrene External Ointment 0.005 % 1 QL

calcitriol external ointment 3 mcg/gm 1

Dritho-Creme HP External Cream 1 % 2

tazarotene external cream 0.1 % 1

Tazorac External Cream 0.05 % 3

Tazorac External Gel 0.05 %, 0.1 % 3

Zithranol External Shampoo 1 % 3

*Antiseborrheic Combinations*** - Drugs For The Skin

Nutraseb External Cream 3

Promiseb External Cream 3

sodium sulfacetamide wash external liquid 10 % 1

*Antiseborrheic Products*** - Drugs For The Skin

glycolic acid solution 70 % 3

Ovace Plus External Cream 10 % 3

Ovace Plus External Foam 9.8 % 3

Ovace Plus External Lotion 9.8 % 3

selenium sulfide external lotion 2.5 % 1

selenium sulfide external shampoo 2.3 % 1

sodium sulfacetamide external shampoo 10 % 1

sulfacetamide sodium external gel 10 % (cleans) 1

sulfacetamide sodium external liquid 10 % 1

*Antiviral Topical Combinations*** - Drugs For The Skin

Xerese External Cream 5-1 % 3 QL

*Antivirals - Topical*** - Drugs For The Skin

acyclovir external cream 5 % 1

acyclovir external ointment 5 % 1

Denavir External Cream 1 % 3

*Burn Products*** - Drugs For The Skin

mafenide acetate external packet 5 % 1

silver sulfadiazine external cream 1 % 1

SSD External Cream 1 % 1

Sulfamylon External Cream 85 MG/GM 3

*Cauterizing Agent Combinations*** - Drugs For The Skin

Arzol Silver Nit Applicators External 75-25 % 1

*Cauterizing Agents*** - Drugs For The Skin

silver nitrate external solution 0.5 %, 10 %, 25 %, 50 %

3

Tri-Chlor External Liquid 80 % 3


73


*Corticosteroids - Topical*** - Drugs For The Skin

Ala Scalp External Lotion 2 % 3

ala-cort external cream 2.5 % 1

alclometasone dipropionate external cream 0.05 % 1

alclometasone dipropionate external ointment 0.05 % 1

amcinonide external cream 0.1 % 1

amcinonide external lotion 0.1 % 1

amcinonide external ointment 0.1 % 1

ApexiCon E External Cream 0.05 % 1

betamethasone dipropionate aug external cream 0.05 %

1

betamethasone dipropionate aug external gel 0.05 % 1

betamethasone dipropionate aug external lotion 0.05 %

1

betamethasone dipropionate aug external ointment0.05 %

1

betamethasone dipropionate external cream 0.05 % 1

betamethasone dipropionate external lotion 0.05 % 1

betamethasone dipropionate external ointment 0.05 % 1

betamethasone valerate external cream 0.1 % 1

betamethasone valerate external foam 0.12 % 1

betamethasone valerate external lotion 0.1 % 1

betamethasone valerate external ointment 0.1 % 1

Bryhali External Lotion 0.01 % 3

Capex External Shampoo 0.01 % 3

clobetasol prop emollient base external cream 0.05 % 1

clobetasol propionate e external cream 0.05 % 1

clobetasol propionate emulsion external foam 0.05 % 1

clobetasol propionate external cream 0.05 % 1

clobetasol propionate external foam 0.05 % 1

clobetasol propionate external gel 0.05 % 1

clobetasol propionate external liquid 0.05 % 1

clobetasol propionate external lotion 0.05 % 1

clobetasol propionate external ointment 0.05 % 1

clobetasol propionate external shampoo 0.05 % 1

clobetasol propionate external solution 0.05 % 1

clocortolone pivalate external cream 0.1 % 1

Clodan External Shampoo 0.05 % 1

Cordran External Tape 4 MCG/SQCM 3

Desonate External Gel 0.05 % 3

desonide external cream 0.05 % 1

desonide external lotion 0.05 % 1

desonide external ointment 0.05 % 1


74


desoximetasone external cream 0.05 %, 0.25 % 1

desoximetasone external gel 0.05 % 1

desoximetasone external liquid 0.25 % 1

desoximetasone external ointment 0.05 %, 0.25 % 1

diflorasone diacetate external cream 0.05 % 1

diflorasone diacetate external ointment 0.05 % 1

fluocinolone acetonide body external oil 0.01 % 1

fluocinolone acetonide external cream 0.01 %, 0.025 %

1

fluocinolone acetonide external ointment 0.025 % 1

fluocinolone acetonide external solution 0.01 % 1

fluocinolone acetonide scalp external oil 0.01 % 1

fluocinonide emulsified base external cream 0.05 % 1

fluocinonide external cream 0.05 %, 0.1 % 1

fluocinonide external gel 0.05 % 1

fluocinonide external ointment 0.05 % 1

fluocinonide external solution 0.05 % 1

flurandrenolide external cream 0.05 % 1

flurandrenolide external lotion 0.05 % 1

flurandrenolide external ointment 0.05 % 1

fluticasone propionate external cream 0.05 % 1

fluticasone propionate external lotion 0.05 % 1

fluticasone propionate external ointment 0.005 % 1

halcinonide external cream 0.1 % 1

halobetasol propionate external cream 0.05 % 1

halobetasol propionate external ointment 0.05 % 1

Halog External Ointment 0.1 % 3

hydrocortisone butyr lipo base external cream 0.1 % 1

hydrocortisone butyrate external cream 0.1 % 1

hydrocortisone butyrate external lotion 0.1 % 1

hydrocortisone butyrate external ointment 0.1 % 1

hydrocortisone butyrate external solution 0.1 % 1

hydrocortisone external cream 2.5 % 1

hydrocortisone external lotion 2.5 % 1

hydrocortisone external ointment 2.5 % 1

hydrocortisone valerate external cream 0.2 % 1

hydrocortisone valerate external ointment 0.2 % 1

mometasone furoate external cream 0.1 % 1

mometasone furoate external ointment 0.1 % 1

mometasone furoate external solution 0.1 % 1

Nolix External Cream 0.05 % 1

Nolix External Lotion 0.05 % 1


75


NuCort External Lotion 2 % 3

Pandel External Cream 0.1 % 2

prednicarbate external cream 0.1 % 1

prednicarbate external ointment 0.1 % 1

psorcon external cream 0.05 % 3

Sernivo External Emulsion 0.05 % 3

Texacort External Solution 2.5 % 3

triamcinolone acetonide external aerosol solution0.147 mg/gm

1

triamcinolone acetonide external cream 0.025 %, 0.1 %

1

triamcinolone acetonide external lotion 0.025 %, 0.1 % 1

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

1

Trianex External Ointment 0.05 % 3

Triderm External Cream 0.1 % 1

Ultravate External Lotion 0.05 % 3

Verdeso External Foam 0.05 % 3

*Emollient Combinations*** - Drugs For The Skin

lactic acid e external cream 10-3500 %-unt/30gm 1

*Emollient/Keratolytic Agents*** - Drugs For The Skin

urea external cream 39 %, 45 % 1

Uredeb External Cream 39 % 1

*Emollients*** - Drugs For The Skin

glycerin external liquid 2

gnp glycerin external liquid 99.5 % 2

hm glycerin external liquid , 99.5 % 2

qc glycerin external liquid 99.5 % 2

ra glycerin external liquid 2

sm glycerin external liquid 99.5 % 2

*Enzymes - Topical*** - Drugs For The Skin

Santyl External Ointment 250 UNIT/GM 3 QL

*Eyelid Cleansers & Lubricants*** - Drugs For The Skin

Avenova External Solution 0.01 % 3

*Imidazole-Related Antifungals - Topical*** - Drugs For The Skin

econazole nitrate external cream 1 % 1

Ecoza External Foam 1 % 3ST; Age Restriction Applies (Min 12 Years)

Ertaczo External Cream 2 % 3 ST

Exelderm External Solution 1 % 3 ST

Jublia External Solution 10 % 3 ST; QL


76


ketoconazole external cream 2 % 1

ketoconazole external foam 2 % 1

ketoconazole external shampoo 2 % 1

oxiconazole nitrate external cream 1 % 1

Oxistat External Lotion 1 % 3 ST

sulconazole nitrate external cream 1 % 1

Xolegel External Gel 2 % 3 ST

*Immunomodulators Imidazoquinolinamines - Topical*** - Drugs For The Skin

imiquimod external cream 5 % 1

Zyclara External Cream 3.75 % 2QL; Age Restriction Applies (Min 12 Years)

Zyclara Pump External Cream 2.5 % 2QL; Age Restriction Applies (Min 12 Years)

*Keratolytic And/Or Antimitotic Combinations*** - Drugs For The Skin

bensal hp external ointment 3-6 % 3

pyrogallic acid external ointment 25-2 % 3

*Keratolytic/Antimitotic Agents*** - Drugs For The Skin

Condylox External Gel 0.5 % 3

podocon external solution 25 % 3

podofilox external solution 0.5 % 1

salicylic acid er external solution 28.5 % 1

salicylic acid external foam 6 % 1

salicylic acid external gel 6 % 1

salicylic acid external liquid 27.5 % 1

salicylic acid external lotion 6 % 1

salicylic acid external shampoo 6 % 1

salicylic acid external solution 26 % 1

salicylic acid wart remover external liquid 27.5 % 1

*Local Anesthetics - Topical*** - Drugs For The Skin

7T Lido External Gel 2 % 1 QL

Anacaine External Ointment 10 % 3

Astero External Gel 4 % 3

LDO Plus External Gel 4 % 3

lidocaine external ointment 5 % 1

lidocaine external patch 5 % 1 QL

lidocaine hcl external solution 4 % 1

lidocaine hcl urethral/mucosal external gel 2 % 1 QL

premium lidocaine external ointment 5 % 1


77


*Macrolide Immunosuppressants - Topical*** - Drugs For The Skin

pimecrolimus external cream 1 % 1QL; Age Restriction Applies (Min 2 Years)

tacrolimus external ointment 0.03 %, 0.1 % 1 Age Restriction Applies (Min 2 Years)

*Misc. Dermatological Products*** - Drugs For The Skin

alevamax external cream 3

Alevicyn Antipruritic External Gel 3

Alevicyn Antipruritic SG External Gel 3

atopaderm external cream 3

Atopiclair External Cream 3

Dexeryl External Cream 3

Eletone External Cream 3

HPR External Foam 3

HPR Plus External Cream 3

HPR Plus External Foam 3

HPR PLUS HydroGel External Kit 3

Hylatopic Plus External Cream 3

Hylatopic Plus External Foam 3

Hylatopic Plus External Lotion 3

Levicyn External Gel 3

MB HydroGel External Kit 3

MimyX External Cream 3

Neocera External Cream 3

Neosalus CP External Cream 3

Neosalus External Cream 3

Neosalus External Foam 3

Neosalus External Lotion 3

Nivatopic Plus External Cream 3

PR Cream External Kit 3

Presera External Foam 3

PruClair External Cream 3

PruMyx External Cream 3

remigen external cream 3

Sebuderm External Gel 3

Tetrix External Cream 3

Xeralux External Cream 3

*Misc. Topical*** - Drugs For The Skin

arnica flower tincture 3

boric acid external granules 3

Drysol External Solution 20 % 3


78


Qbrexza External Pad 2.4 % 3ST; Age Restriction Applies (Min 9 Years and Max 17 Years)

*Photodynamic Therapy Agents - Topical*** - Drugs For The Skin

Ameluz External Gel 10 % 3

Levulan Kerastick External Solution Reconstituted20 %

3

*Rosacea Agents*** - Drugs For The Skin

azelaic acid external gel 15 % 1

doxycycline oral capsule delayed release 40 mg 1

Finacea External Foam 15 % 3

metronidazole external cream 0.75 % 1

metronidazole external gel 0.75 %, 1 % 1

metronidazole external lotion 0.75 % 1

Noritate External Cream 1 % 3

Rosadan External Cream 0.75 % 1

Rosadan External Gel 0.75 % 1

*Scabicides & Pediculicides*** - Drugs For The Skin

Crotan External Lotion 10 % 1

lindane external shampoo 1 % 1

malathion external lotion 0.5 % 1

permethrin external cream 5 % 1

Sklice External Lotion 0.5 % 2 QL

spinosad external suspension 0.9 % 1

*Scar Treatment Products*** - Drugs For The Skin

beau rx external gel 2

Celacyn External Gel 1

CopaSil External Gel 2

KelaRx External Gel 2

Recedo External Gel 2

scarcin external gel 2

scarsilk external gel 2

*Shampoos*** - Drugs For The Skin

Aveeno Active Nat Pure Renewal External 2

Aveeno Active Nat Pure Renewal External Shampoo

2

CLn Healthy Scalp External Shampoo 2

CLn Moisture Rich Gentle External Shampoo 2

Dara External Shampoo 2

DHS Color Safe External Shampoo 2

DHS Conditioning Rinse External Liquid 2

DHS External Shampoo 0.5-0.5 % 2


79


Free & Clear External Shampoo 2

geri-shampoo/shea butter external shampoo 2

Neutrogena External Shampoo 2

Neutrogena Triple Moisture External Shampoo 2

Phacid External Shampoo 2

Ultraswim External Shampoo 2

Ultraswim Ultra Repair External Shampoo 2

*Skin Cleansers*** - Drugs For The Skin

cvs isopropyl alcohol wipes external 70 % 1

essentra wipes 9x9" external 70 % 1

Hyclodex External Solution 0.012 % 3

isopropyl alcohol external 70 % 1

isopropyl alcohol wipes external 70 % 1

ra isopropyl alcohol wipes external 70 % 1

*Skin Protectants*** - Drugs For The Skin

benzoin external tincture 2

mineral oil light external oil , 100 % 2

sm benzoin tincture external tincture 2

*Steroid-Local Anesthetic Combinations*** - Drugs For The Skin

Cortane-B External Lotion 10-10-1 MG/ML 2

Epifoam External Foam 1-1 % 3

Pramosone External Cream 1-1 % 1

Pramosone External Lotion 1-1 %, 1-2.5 % 1

Pramosone External Ointment 1-1 %, 1-2.5 % 3

*Topical Anesthetic Combinations*** - Drugs For The Skin

Cetacaine External Aerosol 2-2-14 % 3

lidocaine-prilocaine external cream 2.5-2.5 % 1

Synera External Patch 70-70 MG 3

*Topical Anesthetic Gasses*** - Drugs For The Skin

ethyl chloride external aerosol 1

Gebauers Pain Ease External Aerosol 3

Gebauers Spray and Stretch External Aerosol 3

*Topical Selective Retinoid X Receptor Agonists*** - Drugs For The Skin

Targretin External Gel 1 % 2

*Topical Steroid Combinations*** - Drugs For The Skin

calcipotriene-betameth diprop external ointment0.005-0.064 %

1

Duobrii Lotion 0.01-0.045 % External 0.01-0.045 % 3


80


Enstilar External Foam 0.005-0.064 % 3

Taclonex External Suspension 0.005-0.064 % 3

*Wound Care - Growth Factor Agents*** - Drugs For The Skin

Regranex External Gel 0.01 % 2 QL

*Wound Care Combinations*** - Drugs For The Skin

balsam peru-castor oil external ointment 3

bpco external ointment 3

Dermulcera External Ointment 3

Venelex External Ointment 3

*Diagnostic Products*

*Diagnostic Tests***

Chemstrip K In Vitro Strip 1

ketone test in vitro strip 1

Ketostix In Vitro Strip 1

OneTouch Verio In Vitro Strip 1 QL

ReliOn Ketone In Vitro Strip 1

ReliOn Ketone Test In Vitro Strip 1

*Multiple Urine Tests***

Chemstrip uGK In Vitro Strip 3

CVS Ketone Care In Vitro Strip 3

Keto-Diastix In Vitro Strip 3

*Dietary Products/Dietary Management Products* - Drugs For Nutrition

*Sweeteners*** - Drugs For Nutrition

sodium saccharin granules 3

sodium saccharin powder 2

*Digestive Aids* - Drugs For The Stomach

*Digestive Enzymes*** - Drugs For The Stomach

Creon Oral Capsule Delayed Release Particles12000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

2

Pancreaze Oral Capsule Delayed Release Particles10500 UNIT, 16800 UNIT, 21000 UNIT, 2600 UNIT, 4200 UNIT

3

Pertzye Oral Capsule Delayed Release Particles16000 UNIT, 24000-86250 UNIT, 4000 UNIT, 8000 UNIT

2

Sucraid Oral Solution 8500 UNIT/ML 3 PA

Viokace Oral Tablet 10440 UNIT, 20880 UNIT 3

Zenpep Oral Capsule Delayed Release Particles10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT

3


81


*Direct-Acting P2y12 Inhibitors*** - Drugs For The Blood

*Direct-Acting P2y12 Inhibitors*** - Drugs For The Blood

Brilinta Oral Tablet 60 MG, 90 MG 2 QL

*Diuretics* - Drugs For The Heart

*Carbonic Anhydrase Inhibitors*** - Drugs For High Blood Pressure

acetazolamide er oral capsule extended release 12 hour 500 mg

1

acetazolamide oral tablet 125 mg, 250 mg 1

Keveyis Oral Tablet 50 MG 3 PA; QL

methazolamide oral tablet 25 mg, 50 mg 1

*Diuretic Combinations*** - Drugs For High Blood Pressure

Aldactazide Oral Tablet 50-50 MG 3

amiloride-hydrochlorothiazide oral tablet 5-50 mg 1

spironolactone-hctz oral tablet 25-25 mg 1

triamterene-hctz oral capsule 37.5-25 mg 1

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1

*Loop Diuretics*** - Drugs For High Blood Pressure

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1

ethacrynic acid oral tablet 25 mg 1

furosemide oral solution 10 mg/ml, 8 mg/ml 1

furosemide oral tablet 20 mg, 40 mg, 80 mg 1

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1

*Potassium Sparing Diuretics*** - Drugs For High Blood Pressure

amiloride hcl oral tablet 5 mg 1

CaroSpir Oral Suspension 25 MG/5ML 3Age Restriction Applies (Max 12 Years)

spironolactone oral tablet 100 mg, 25 mg, 50 mg 1

triamterene oral capsule 100 mg, 50 mg 1

*Thiazides And Thiazide-Like Diuretics*** - Drugs For High Blood Pressure

chlorothiazide oral tablet 250 mg, 500 mg 1

chlorthalidone oral tablet 25 mg, 50 mg 1

Diuril Oral Suspension 250 MG/5ML 3

hydrochlorothiazide oral capsule 12.5 mg 1

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1

indapamide oral tablet 1.25 mg, 2.5 mg 1

metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1


82


*Dopamine And Norepinephrine Reuptake Inhibitors (Dnris)*** - Drugs For The Nervous System

*Dopamine And Norepinephrine Reuptake Inhibitors (Dnris)*** - Drugs For The Nervous System

Sunosi Oral Tablet 150 MG, 75 MG 3 ST; QL

*Endocrine And Metabolic Agents - Misc.* - Hormones

*Bisphosphonates*** - Drugs For Menopause And Bone Loss

alendronate sodium oral solution 70 mg/75ml 1

alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg

1 QL

Binosto Oral Tablet Effervescent 70 MG 3

Fosamax Plus D Oral Tablet 70-2800 MG-UNIT, 70-5600 MG-UNIT

3

ibandronate sodium oral tablet 150 mg 1 QL

risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg

1 QL

risedronate sodium oral tablet delayed release 35 mg 1 QL

*Calcimimetic Agents*** - Drugs For Menopause And Bone Loss

cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg 1

Sensipar Oral Tablet 30 MG, 60 MG, 90 MG 2

*Calcitonins*** - Drugs For Menopause And Bone Loss

calcitonin (salmon) nasal solution 200 unit/act 1

*Carnitine Replenisher - Agents*** - Drugs For Menopause And Bone Loss

levocarnitine oral solution 1 gm/10ml 1

levocarnitine oral tablet 330 mg 1

*Dopamine Receptor Agonists*** - Drugs For Women

cabergoline oral tablet 0.5 mg 1

*Fabry Disease - Agents*** - Drugs For Menopause And Bone Loss

Galafold Oral Capsule 123 MG 3 PA; QL

*Gnrh/Lhrh Antagonists*** - Drugs For Women

Orilissa Oral Tablet 150 MG, 200 MG 3 QL

*Growth Hormone Receptor Antagonists*** - Drugs For Growth

Somavert Subcutaneous Solution Reconstituted10 MG, 15 MG, 20 MG, 25 MG, 30 MG

3 PA; QL


83


*Growth Hormones*** - Drugs For Growth

Genotropin MiniQuick Subcutaneous Solution Reconstituted 0.2 MG, 0.4 MG, 0.6 MG, 0.8 MG, 1 MG, 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG

3 PA

Genotropin Subcutaneous Solution Reconstituted12 MG, 5 MG

3 PA

Humatrope Injection Solution Reconstituted 12 MG, 24 MG, 5 MG, 6 MG

2 PA

Norditropin FlexPro Subcutaneous Solution 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

3 PA

Nutropin AQ NuSpin 10 Subcutaneous Solution 10 MG/2ML

3 PA


3 PA


3 PA

Omnitrope Subcutaneous Solution 10 MG/1.5ML, 5 MG/1.5ML

3 PA

Omnitrope Subcutaneous Solution Reconstituted5.8 MG

3 PA

Saizen Injection Solution Reconstituted 5 MG, 8.8 MG

3 PA

Saizenprep Injection Solution Reconstituted 8.8 MG

3 PA

Serostim Subcutaneous Solution Reconstituted 4 MG, 5 MG, 6 MG

3 PA

Zomacton Subcutaneous Solution Reconstituted10 MG, 5 MG

3 PA

Zorbtive Subcutaneous Solution Reconstituted 8.8 MG

3 PA

*Hereditary Tyrosinemia Type 1 (Ht-1) Treatment - Agents*** - Drugs For Menopause And Bone Loss

nitisinone oral capsule 10 mg, 2 mg, 5 mg 1 PA

Nityr Oral Tablet 10 MG, 2 MG, 5 MG 3 PA

Orfadin Oral Capsule 10 MG, 2 MG, 20 MG, 5 MG 3 PA

Orfadin Oral Suspension 4 MG/ML 3 PA

*Homocystinuria Treatment - Agents*** - Drugs For Menopause And Bone Loss

Cystadane Oral Powder 2

*Hyperammonemia Treatment - Agents*** - Drugs For Menopause And Bone Loss

Carbaglu Oral Tablet 200 MG 3 PA

*Hyperparathyroid Treatment - Vitamin D Analogs*** - Drugs For Menopause And Bone Loss

calcitriol oral capsule 0.25 mcg, 0.5 mcg 1

calcitriol oral solution 1 mcg/ml 1

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg 1


84


paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1

Rayaldee Oral Capsule Extended Release 30 MCG 3

*Insulin-Like Growth Factors (Somatomedins)*** - Hormones

Increlex Subcutaneous Solution 40 MG/4ML 2 PA

*Parathyroid Hormone And Derivatives*** - Drugs For Menopause And Bone Loss

Natpara Subcutaneous Cartridge 100 MCG, 25 MCG, 50 MCG, 75 MCG

3 PA; QL

Tymlos Subcutaneous Solution Pen-Injector 3120 MCG/1.56ML

2 PA

*Phenylketonuria Treatment - Agents*** - Drugs For Menopause And Bone Loss

Kuvan Oral Packet 100 MG, 500 MG 2 PA

Kuvan Oral Tablet Soluble 100 MG 2 PA

Palynziq Subcutaneous Solution Prefilled Syringe10 MG/0.5ML, 2.5 MG/0.5ML, 20 MG/ML

3 PA

*Selective Estrogen Receptor Modulators (Serms)*** - Drugs For Menopause And Bone Loss

Osphena Oral Tablet 60 MG 3 Female Only; QL

raloxifene hcl oral tablet 60 mg 1 QL

*Selective Vasopressin V2-Receptor Antagonists*** - Hormones

Jynarque Oral Tablet Therapy Pack 45 & 15 MG, 60 & 30 MG, 90 & 30 MG

3 PA

Samsca Oral Tablet 15 MG, 30 MG 3 PA; QL

*Somatostatic Agents*** - Drugs For Growth

octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

1 PA

SandoSTATIN Injection Solution 100 MCG/ML, 50 MCG/ML, 500 MCG/ML

3 PA

Signifor Subcutaneous Solution 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML

3 PA

*Urea Cycle Disorder - Agents*** - Drugs For Menopause And Bone Loss

Buphenyl Oral Powder 3 GM/TSP 3

Buphenyl Oral Tablet 500 MG 3

Ravicti Oral Liquid 1.1 GM/ML 3 PA; QL

sodium phenylbutyrate oral powder 3 gm/tsp 1

sodium phenylbutyrate oral tablet 500 mg 1

*Vasopressin*** - Hormones

DDAVP Rhinal Tube Nasal Solution 0.01 % 3

desmopressin ace spray refrig nasal solution 0.01 % 1

desmopressin acetate oral tablet 0.1 mg, 0.2 mg 1

desmopressin acetate spray nasal solution 0.01 % 1


85


Stimate Nasal Solution 1.5 MG/ML 2

*Estrogens* - Hormones

*Estrogen & Androgen*** - Drugs For Women

Covaryx HS Oral Tablet 0.625-1.25 MG 1

Covaryx Oral Tablet 1.25-2.5 MG 1

EEMT HS Oral Tablet 0.625-1.25 MG 1

EEMT Oral Tablet 1.25-2.5 MG 1

est estrogens-methyltest ds oral tablet 1.25-2.5 mg 1

est estrogens-methyltest hs oral tablet 0.625-1.25 mg 1

est estrogens-methyltest oral tablet 1.25-2.5 mg 1

*Estrogen & Progestin*** - Drugs For Women

Amabelz Oral Tablet 0.5-0.1 MG, 1-0.5 MG 1

Angeliq Oral Tablet 0.25-0.5 MG, 0.5-1 MG 2

Climara Pro Transdermal Patch Weekly 0.045-0.015 MG/DAY

2 QL

CombiPatch Transdermal Patch Twice Weekly0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY

3 QL

estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg

1

Jinteli Oral Tablet 1-5 MG-MCG 1

Lopreeza Oral Tablet 1-0.5 MG 1

Mimvey Oral Tablet 1-0.5 MG 1

norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

1

Prefest Oral Tablet 1/1-0.09 MG (15/15) 3

Premphase Oral Tablet 0.625-5 MG 2

Prempro Oral Tablet 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

2

*Estrogens*** - Drugs For Women

Alora Transdermal Patch Twice Weekly 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

3 QL

Divigel Transdermal Gel 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM

3 QL

Divigel Transdermal Gel 1.25 MG/1.25GM 3

Elestrin Transdermal Gel 0.52 MG/0.87 GM (0.06%) 3 QL

estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1

estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

1 QL

estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

1 QL

Estrogel Transdermal Gel 0.75 MG/1.25 GM (0.06%) 3

Evamist Transdermal Solution 1.53 MG/SPRAY 3 QL


86


Menest Oral Tablet 0.3 MG, 0.625 MG, 1.25 MG 1

Menostar Transdermal Patch Weekly 14 MCG/24HR

3 QL

Premarin Oral Tablet 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

2

*Estrogen-Selective Estrogen Receptor Modulator Comb*** - Hormones

*Estrogen-Selective Estrogen Receptor Modulator Comb*** - Hormones

Duavee Oral Tablet 0.45-20 MG 3Female Only; Age Restriction Applies (Max 74 Years)

*Farnesoid X Receptor (Fxr) Agonists*** - Drugs For The Liver

*Farnesoid X Receptor (Fxr) Agonists*** - Drugs For The Liver

Ocaliva Oral Tablet 10 MG, 5 MG 3 ST

*Fluoroquinolones* - Drugs For Infections

*Fluoroquinolones*** - Antibiotics

Baxdela Oral Tablet 450 MG 3

Cipro Oral Suspension Reconstituted 250 MG/5ML (5%)

3

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg

1

levofloxacin oral solution 25 mg/ml 1

levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1

moxifloxacin hcl oral tablet 400 mg 1

ofloxacin oral tablet 300 mg, 400 mg 1

*Gastrointestinal Agents - Misc.* - Drugs For The Stomach

*Gallstone Solubilizing Agents*** - Drugs For The Stomach

ursodiol oral capsule 300 mg 1

ursodiol oral tablet 250 mg, 500 mg 1

*Gastrointestinal Antiallergy Agents*** - Drugs For The Stomach

cromolyn sodium oral concentrate 100 mg/5ml 1

*Gastrointestinal Chloride Channel Activators*** - Drugs For Irritable Bowel Syndrome

Amitiza Oral Capsule 24 MCG, 8 MCG 2QL; Age Restriction Applies (Min 18 Years)

*Gastrointestinal Stimulants*** - Drugs For The Stomach

metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml

1

metoclopramide hcl oral tablet 10 mg, 5 mg 1

metoclopramide hcl oral tablet dispersible 10 mg 3


87


metoclopramide hcl oral tablet dispersible 5 mg 1

*Glucagon-Like Peptide-2 (Glp-2) Analogs*** - Drugs For The Stomach

Gattex Subcutaneous Kit 5 MG 3 PA

*Ibs Agent - Guanylate Cyclase-C (Gc-C) Agonists*** - Drugs For Irritable Bowel Syndrome

Linzess Oral Capsule 145 MCG, 290 MCG, 72 MCG 2QL; Age Restriction Applies (Min 18 Years)

*Ibs Agent - Selective 5-Ht3 Receptor Antagonists*** - Drugs For Irritable Bowel Syndrome

alosetron hcl oral tablet 0.5 mg, 1 mg 1Female Only; Age Restriction Applies (Min 18 Years)

*Inflammatory Bowel Agents*** - Drugs For Inflammatory Bowel Disease

balsalazide disodium oral capsule 750 mg 1

Dipentum Oral Capsule 250 MG 3

mesalamine er oral capsule extended release 24 hour0.375 gm

1 QL

mesalamine oral capsule delayed release 400 mg 1 QL

mesalamine oral tablet delayed release 1.2 gm, 800 mg

1 QL

mesalamine rectal enema 4 gm 1

mesalamine rectal suppository 1000 mg 1

mesalamine-cleanser rectal kit 4 gm 1

Pentasa Oral Capsule Extended Release 250 MG, 500 MG

2 QL

SfRowasa Rectal Enema 4 GM/60ML 3

sulfasalazine oral tablet 500 mg 1

sulfasalazine oral tablet delayed release 500 mg 1

*Intestinal Acidifiers*** - Drugs For The Stomach

enulose oral solution 10 gm/15ml 1

generlac oral solution 10 gm/15ml 1

lactulose encephalopathy oral solution 10 gm/15ml 1

*Peripheral Opioid Receptor Antagonists*** - Drugs For The Stomach

Entereg Oral Capsule 12 MG 3

Movantik Oral Tablet 12.5 MG, 25 MG 2 QL

Relistor Oral Tablet 150 MG 3 QL

Relistor Subcutaneous Solution 12 MG/0.6ML, 8 MG/0.4ML

3 QL

Symproic Oral Tablet 0.2 MG 3

*Phosphate Binder Agents*** - Drugs For The Stomach

Auryxia Oral Tablet 1 GM 210 MG(Fe) 3


88


calcium acetate (phos binder) oral capsule 667 mg 1

calcium acetate (phos binder) oral tablet 667 mg 1

Fosrenol Oral Packet 1000 MG, 750 MG 2

Phoslyra Oral Solution 667 MG/5ML 3

sevelamer carbonate oral packet 0.8 gm, 2.4 gm 1

sevelamer carbonate oral tablet 800 mg 1

sevelamer hcl oral tablet 400 mg, 800 mg 1

Velphoro Oral Tablet Chewable 500 MG 3 QL

*Genitourinary Agents - Miscellaneous* - Drugs For The Urinary System

*5-Alpha Reductase Inhibitors*** - Drugs For The Prostate

dutasteride oral capsule 0.5 mg 1 QL

finasteride oral tablet 5 mg 1 Male Only; QL

*Alpha 1-Adrenoceptor Antagonists*** - Drugs For The Prostate

alfuzosin hcl er oral tablet extended release 24 hour10 mg

1 QL

Cardura XL Oral Tablet Extended Release 24 Hour4 MG, 8 MG

3

silodosin oral capsule 4 mg, 8 mg 1 QL

tamsulosin hcl oral capsule 0.4 mg 1

*Citrates*** - Drugs For Infections

cytra k crystals oral packet 3300-1002 mg 1

cytra-2 oral solution 500-334 mg/5ml 1

cytra-k oral solution 1100-334 mg/5ml 1

Oracit Oral Solution 490-640 MG/5ML 3

potassium citrate er oral tablet extended release 10 meq (1080 mg), 15 meq (1620 mg), 5 meq (540 mg)

1

potassium citrate-citric acid oral solution 1100-334 mg/5ml

1

sod citrate-citric acid oral solution 500-334 mg/5ml 1

Taron-Crystals Oral Packet 3300-1002 MG 1

tricitrates oral solution 550-500-334 mg/5ml 1

*Cystinosis Agents*** - Drugs For The Urinary System

Cystagon Oral Capsule 150 MG, 50 MG 2 PA

Procysbi Oral Capsule Delayed Release 25 MG, 75 MG

3 PA

Procysbi Oral Packet 300 MG, 75 MG 3 PA

*Interstitial Cystitis Agents*** - Drugs For The Urinary System

Elmiron Oral Capsule 100 MG 2

*Phosphates*** - Drugs For Infections

K-Phos No 2 Oral Tablet 305-700 MG 3


89


*Prostatic Hypertrophy Agent Combinations*** - Drugs For The Prostate

dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg 1

*Urinary Analgesics*** - Drugs For Infections

Phenazo Oral Tablet 200 MG 1

phenazopyridine hcl oral tablet 100 mg, 200 mg 1

*Urinary Stone Agents*** - Drugs For The Urinary System

Lithostat Oral Tablet 250 MG 3

Thiola EC Oral Tablet Delayed Release 100 MG, 300 MG

3

Thiola Oral Tablet 100 MG 3

*Glycopeptides*** - Drugs For Infections

*Glycopeptides*** - Drugs For Infections

Firvanq Oral Solution Reconstituted 25 MG/ML, 50 MG/ML

3

vancomycin hcl oral capsule 125 mg, 250 mg 1

*Gout Agents* - Drugs For Pain And Fever

*Gout Agent Combinations*** - Gout Drugs

colchicine-probenecid oral tablet 0.5-500 mg 1

*Gout Agents*** - Gout Drugs

allopurinol oral tablet 100 mg, 300 mg 1

colchicine oral capsule 0.6 mg 1 QL

colchicine oral tablet 0.6 mg 1 QL

febuxostat oral tablet 40 mg, 80 mg 1 QL

Gloperba Oral Solution 0.6 MG/5ML 3

*Uricosurics*** - Gout Drugs

probenecid oral tablet 500 mg 1

*Hematological Agents - Misc.* - Drugs For The Blood

*Cyclopentyltriazolopyrimidine (Cptp) Derivatives*** - Drugs For The Blood

Brilinta Oral Tablet 60 MG, 90 MG 2 QL

*Hematorheologic Agents*** - Drugs For The Blood

pentoxifylline er oral tablet extended release 400 mg 1

*Phosphodiesterase Iii Inhibitors*** - Drugs For The Blood

cilostazol oral tablet 100 mg, 50 mg 1

*Platelet Aggregation Inhibitor Combinations*** - Drugs For The Blood

aspirin-dipyridamole er oral capsule extended release 12 hour 25-200 mg

1

Yosprala Oral Tablet Delayed Release 325-40 MG, 81-40 MG

3


90


*Platelet Aggregation Inhibitors*** - Drugs For The Blood

dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1

*Quinazoline Agents*** - Drugs For The Blood

anagrelide hcl oral capsule 0.5 mg, 1 mg 1

*Thienopyridine Derivatives*** - Drugs For The Blood

clopidogrel bisulfate oral tablet 300 mg, 75 mg 1

prasugrel hcl oral tablet 10 mg, 5 mg 1 QL

*Hematopoietic Agents* - Drugs For Nutrition

*Agents For Gaucher Disease*** - Drugs For Nutrition

Cerdelga Oral Capsule 84 MG 3 PA; QL

miglustat oral capsule 100 mg 1 PA; QL

Zavesca Oral Capsule 100 MG 3 PA; QL

*Cobalamins*** - Drugs For Nutrition

cyanocobalamin injection solution 1000 mcg/ml 1

*Cytotoxic Agents*** - Drugs For Nutrition

Droxia Oral Capsule 200 MG, 300 MG, 400 MG 3

Siklos Oral Tablet 100 MG, 1000 MG 3

*Folic Acid/Folates*** - Drugs For Nutrition

folic acid oral tablet 1 mg 1

kp folic acid oral tablet 1 mg 1

*Thrombopoietin (Tpo) Receptor Agonists*** - Drugs For Nutrition

Doptelet Oral Tablet 20 MG 3 PA

Mulpleta Oral Tablet 3 MG 3 PA

Promacta Oral Packet 12.5 MG, 25 MG 3 PA

Promacta Oral Tablet 12.5 MG, 25 MG, 50 MG, 75 MG

2 PA; QL

*Hemoglobin S (Hbs) Polymerization Inhibitors*** - Drugs For The Blood

*Hemoglobin S (Hbs) Polymerization Inhibitors*** - Drugs For The Blood

Oxbryta Oral Tablet 500 MG 3 PA

*Hemostatics* - Drugs For The Blood

*Hemostatics - Systemic*** - Drugs To Prevent Bleeding

Amicar Oral Solution 0.25 GM/ML 3

aminocaproic acid oral solution 0.25 gm/ml 1

aminocaproic acid oral tablet 1000 mg, 500 mg 1

tranexamic acid oral tablet 650 mg 1 Female Only; QL


91


*Hemostatics - Topical*** - Drugs To Prevent Bleeding

monsels ferric subsulfate external solution 2

*Hepatitis C Agent - Combinations*** - Drugs For Infections

*Hepatitis C Agent - Combinations*** - Drugs For Infections

Epclusa Oral Tablet 400-100 MG 2 PA; QL

Harvoni Oral Tablet 45-200 MG, 90-400 MG 2 PA; QL

Mavyret Oral Tablet 100-40 MG 2 PA; QL

Vosevi Oral Tablet 400-100-100 MG 2 PA; QL

*Hereditary Orotic Aciduria Treatment - Agents** - Drugs That Alter Metabolism

*Hereditary Orotic Aciduria Treatment - Agents** - Drugs That Alter Metabolism

Xuriden Oral Packet 2 GM 3 PA

*Histamine H3-Receptor Antagonist/Inverse Agonists*** - Drugs For The Nervous System

*Histamine H3-Receptor Antagonist/Inverse Agonists*** - Drugs For The Nervous System

Wakix Oral Tablet 17.8 MG, 4.45 MG 3 ST

*Hypnotics* - Drugs For The Nervous System

*Barbiturate Hypnotics*** - Drugs For Insomnia

phenobarbital oral elixir 20 mg/5ml 1

phenobarbital oral solution 20 mg/5ml 1

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

1

Seconal Oral Capsule 100 MG 2

*Benzodiazepine Hypnotics*** - Drugs For Seizures /Personality Disorder/Nerve Pain

estazolam oral tablet 1 mg, 2 mg 1

flurazepam hcl oral capsule 15 mg, 30 mg 1

quazepam oral tablet 15 mg 1

temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg

1 QL

triazolam oral tablet 0.125 mg, 0.25 mg 1

*Hypnotics - Tricyclic Agents*** - Drugs For Insomnia

Silenor Oral Tablet 3 MG, 6 MG 3 QL

*Non-Benzodiazepine - Gaba-Receptor Modulators*** - Drugs For Insomnia

Edluar Sublingual Tablet Sublingual 10 MG, 5 MG 3 QL

eszopiclone oral tablet 1 mg, 2 mg, 3 mg 1 QL

zaleplon oral capsule 10 mg, 5 mg 1 QL


92


zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 mg

1 QL

zolpidem tartrate oral tablet 10 mg, 5 mg 1 QL

zolpidem tartrate sublingual tablet sublingual 1.75 mg, 3.5 mg

1 QL

*Selective Melatonin Receptor Agonists*** - Drugs For Insomnia

Hetlioz Oral Capsule 20 MG 3 PA; QL

ramelteon oral tablet 8 mg 1 QL

*Ibs Agent - Mu-Opioid Receptor Agonists*** - Drugs For The Stomach

*Ibs Agent - Mu-Opioid Receptor Agonists*** - Drugs For The Stomach

Viberzi Oral Tablet 100 MG, 75 MG 2 QL

*Insulin-Incretin Mimetic Combinations*** - Hormones

*Insulin-Incretin Mimetic Combinations*** - Hormones

Soliqua Subcutaneous Solution Pen-Injector 100-33 UNT-MCG/ML

2 ST; QL

Xultophy Subcutaneous Solution Pen-Injector 100-3.6 UNIT-MG/ML

2 ST; QL

*Interleukin-5 Antagonists (Igg1 Kappa)*** - Drugs For The Lungs

*Interleukin-5 Antagonists (Igg1 Kappa)*** - Drugs For The Lungs

Fasenra Pen Subcutaneous Solution Auto-Injector30 MG/ML

3 PA

Nucala Subcutaneous Solution Auto-Injector 100 MG/ML

3 PA

Nucala Subcutaneous Solution Prefilled Syringe100 MG/ML

3 PA

*Isocitrate Dehydrogenase-1 (Idh1) Inhibitors*** - Drugs For Cancer


Tibsovo Oral Tablet 250 MG 3 PA



IDHIFA Oral Tablet 100 MG, 50 MG 3 PA; QL

*Laxatives* - Drugs For The Stomach

*Bowel Evacuant Combinations*** - Drugs To Prevent Constipation

Clenpiq Oral Solution 10-3.5-12 MG-GM -GM/160ML

3


93


GaviLyte-C Oral Solution Reconstituted 240 GM 1

GaviLyte-H Oral Kit 5-210 MG-GM 1

GaviLyte-N with Flavor Pack Oral Solution Reconstituted 420 GM

1

Golytely Oral Solution Reconstituted 227.1 GM 3

MoviPrep Oral Solution Reconstituted 100 GM 3

peg-3350/electrolytes oral solution reconstituted 236 gm

1

PEG-Prep Oral Kit 5-210 MG-GM 1

Plenvu Oral Solution Reconstituted 140 GM 3

Prepopik Oral Packet 10-3.5-12 MG-GM-GM 3

Suprep Bowel Prep Kit Oral Solution 17.5-3.13-1.6 GM/177ML

3

TriLyte Oral Solution Reconstituted 420 GM 1

*Laxatives - Miscellaneous*** - Drugs To Prevent Constipation

constulose oral solution 10 gm/15ml 1

Kristalose Oral Packet 10 GM, 20 GM 1

lactulose oral packet 10 gm 1

lactulose oral solution 10 gm/15ml, 20 gm/30ml 1

sorbitol oral solution 70 % 2

sorbitol rectal solution 70 % 2

*Lubricant Laxatives*** - Drugs To Prevent Constipation

cvs mineral oil oral oil 2

eq mineral oil oral oil 2

goodsense mineral oil oral oil 2

hm mineral oil oral oil 2

mineral oil heavy oral oil 2

mineral oil oral oil 2

qc mineral oil heavy oral oil 2

ra mineral oil oral oil 2

sm mineral oil oral oil 2

*Saline Laxative Mixtures*** - Drugs To Prevent Constipation

OsmoPrep Oral Tablet 1.102-0.398 GM 3

*Stimulant Laxatives*** - Drugs To Prevent Constipation

cascara sagrada oral fluid extract 1 gm/ml 3

*Lymphocyte Function-Associated Antigen-1 (Lfa-1) Antag*** - Drugs For The Eye

*Lymphocyte Function-Associated Antigen-1 (Lfa-1) Antag*** - Drugs For The Eye

Xiidra Ophthalmic Solution 5 % 2 QL


94


*Macrolides* - Drugs For Infections

*Azithromycin*** - Antibiotics

azithromycin oral packet 1 gm 1

azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

1

azithromycin oral tablet 250 mg, 500 mg, 600 mg 1

*Clarithromycin*** - Antibiotics

clarithromycin er oral tablet extended release 24 hour500 mg

1

clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

clarithromycin oral tablet 250 mg, 500 mg 1

*Erythromycins*** - Antibiotics

E.E.S. 400 Oral Tablet 400 MG 1

Ery-Tab Oral Tablet Delayed Release 250 MG, 333 MG, 500 MG

1

Erythrocin Stearate Oral Tablet 250 MG 1

erythromycin base oral capsule delayed release particles 250 mg

1

erythromycin base oral tablet 250 mg, 500 mg 1

erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml, 400 mg/5ml

1

erythromycin ethylsuccinate oral tablet 400 mg 1

*Fidaxomicin*** - Antibiotics

Dificid Oral Tablet 200 MG 2 QL

*Medical Devices* - Medical Supplies And Durable Medical Equipment

*Applicators,Cotton Balls,Etc*** - Medical Supplies And Durable Medical Equipment

Alcoh-Glove Contoured Wipe Pad 1

alcohol pads pad 70 % 1

alcohol prep pad , 70 % 1

alcohol swabs pad , 70 % 1

Alcohol Swabstick Pad , 70 % 1

alcohol wipes pad 70 % 1

alcoh-wipe sheet 1

Aplicare Alcohol Swabstick Pad 70 % 1

BD Swabs Single Use Butterfly Pad 1

CareTouch Alcohol Prep Pad 70 % 1

Curity Alcohol Preps Pad 70 % 1

Curity Alcohol Swabs Pad 1

cvs alcohol prep pads pad 70 % 1

cvs prep pad 70 % 1

Easy Touch Alcohol Prep Medium Pad 70 % 1


95


eql alcohol swabs pad 70 % 1

Fifty50 Alcohol Prep Pad 70 % 1

global alcohol prep ease pad 70 % 1

gnp alcohol swabs pad 70 % 1

h-e-b incontrol alcohol pad 1

hm sterile alcohol prep pad 1

meijer alcohol swabs pad 70 % 1

Pharmacist Choice Alcohol Pad 1

pro comfort alcohol pad 70 % 1

qc alcohol swabs pad 70 % 1

ra alcohol swabs pad 70 % 1

reality swabs pad 1

ReliOn Alcohol Swabs Pad , 70 % 1

saps care alcohol prep pad 70 % 1

saps health alcohol prep pad 70 % 1

saps health care alcohol prep pad 70 % 1

sb alcohol prep pad 70 % 1

Shopko Alcohol Swabs Pad 70 % 1

sm alcohol prep pad , 70 % 1

sure comfort alcohol prep pad 70 % 1

Sure-Prep Alcohol Prep Pad 70 % 1

tgt alcohol swabs pad 70 % 1

true comfort alcohol prep pads pad 70 % 1

UltiCare Alcohol Swabs Pad , 70 % 1

ultilet alcohol swabs pad 1

ultra-care alcohol prep pads pad 70 % 1

Webcol Alcohol Prep Large Pad 70 % 1

Webcol Alcohol Prep Medium Pad 70 % 1

*Glucose Monitoring Test Supplies*** - Medical Supplies And Durable Medical Equipment

Accu-Chek Aviva In Vitro Solution 2

Accu-Chek Compact Plus Control In Vitro Solution2

Accu-Chek Guide Control In Vitro Liquid 2

Accu-Chek SmartView Control In Vitro Liquid 2

Accutrend Glucose Control In Vitro Solution 2

Advance Intuition Control In Vitro Liquid Normal 3

Advance Micro-Draw Control In Vitro Liquid 2

Advance Micro-Draw Normal In Vitro Liquid 2

Advocate Control Solution In Vitro Liquid High , Low

3

Advocate Redi-Code+ Control In Vitro SolutionHigh , Low

3


96


AgaMatrix Control In Vitro Solution 2

AgaMatrix Control In Vitro Solution High , Normal 3

Assure 3 Control In Vitro Liquid 2

Assure 4 Control Level 1 & 2 In Vitro Liquid 2

Assure Dose Control In Vitro Solution Normal 3

Assure Dose Norm/High Control In Vitro Solution 2

Assure II Control In Vitro Liquid 2

Assure II Control Level 1 & 2 In Vitro Liquid 2

Assure Prism Control Level 1&2 In Vitro Solution 2

Assure Pro Control Level 1 & 2 In Vitro Liquid 2

CareSens Control A In Vitro Solution 2

Clever Choice Glucose Control In Vitro LiquidHigh , Low

3

Contour Next Control In Vitro Solution Low , Normal

3

control in vitro solution normal 3

Cool Control A In Vitro Solution 2

Cool Control B In Vitro Solution 2

Dexcom G4 Plat Ped Rcv/Share Device 2 ST

Dexcom G4 Plat Ped Receiver Device 2 ST

Dexcom G4 Platinum Rcv/Share Device 2 ST

Dexcom G4 Platinum Receiver Device 2 ST

Dexcom G4 Platinum Transmitter 2 ST

Dexcom G4 Sensor 2 ST

Dexcom G5 Mob/G4 Plat Sensor 2 ST

Dexcom G5 Mobile Receiver Device 2 ST

Dexcom G5 Mobile Transmitter 2 ST

Dexcom G6 Receiver Device 2 ST

Dexcom G6 Sensor 2 ST

Dexcom G6 Transmitter 2 ST

DiaScreen 10 3

DiaScreen 1B 3

DiaScreen 1G Strip 3

DiaScreen 1K 3

DiaScreen 1K Strip 3

DiaScreen 2GK Strip 3

DiaScreen 2GP 3

DiaScreen 3 3

DiaScreen 4NL 3

DiaScreen 4ObL 3

DiaScreen 4pH 3

DiaScreen 5 3


97


DiaScreen 6 3

DiaScreen 7 3

DiaScreen 8 3

DiaScreen 9 3

diascreen liquid urine control 3

diathrive glucose control soln in vitro liquid 2

diatrue control level 1 in vitro solution low 3

diatrue control level 2 in vitro solution normal 3

diatrue control level 3 in vitro solution high 3

Duo-Care Control Solution In Vitro Liquid 2

easy plus ii control in vitro solution high , low 3

Easy Step Control In Vitro Solution High , Low , Normal

3

easy talk control in vitro solution high , low , normal 3

Easy Touch Control High & Low In Vitro Solution 2

easy trak control in vitro solution high , low , normal 3

EasyGluco Control In Vitro Solution High , Low , Normal

3

EasyGluco Plus Level 1 In Vitro Solution 2

EasyMax 15 Level 1 Control In Vitro Solution 2

EasyMax 15 Level 1-2 Control In Vitro Solution 2

EasyMax 15 Level 2 Control In Vitro Solution 2

EasyMax Control In Vitro Solution High , Low , Normal

3

EasyMax Control Normal/Low In Vitro Solution 2

element compact control 2 in vitro solution 2

element compact control 3 in vitro solution 2

Element Control In Vitro Liquid High , Low , Normal

3

Embrace Control In Vitro Solution Low 3

Embrace Evo Control Level 1 In Vitro Liquid Low 3

Embrace Evo Control Level 2 In Vitro LiquidNormal

3

Embrace Glucose Control In Vitro Liquid High 3

Embrace Pro Glucose Control In Vitro Liquid 2

Embrace Talk Glucose Control In Vitro SolutionHigh , Low

3

EvenCare Control Low/High In Vitro Liquid 2

EvenCare G2 Low/High Control In Vitro Solution 2

EvenCare G3 Low/High Control In Vitro Solution 2

EvenCare Mini Control In Vitro Solution Normal 3

Evolution Control In Vitro Solution Normal 3

FORA Control In Vitro Solution High , Low , Normal

3


98


ForaCare GDH Control In Vitro Solution High , Low , Normal

3

FortisCare Control In Vitro Solution High , Low , Normal

3

FreeStyle Control Solution In Vitro Liquid 2

FreeStyle Libre 14 Day Reader Device 2 ST

FreeStyle Libre 14 Day Sensor 2 ST

FreeStyle Libre Reader Device 2 ST

FreeStyle Libre Sensor System 2 ST

ge100 control in vitro solution normal 3

Glucocard 01 Control In Vitro Liquid 2

Glucocard 01 Control In Vitro Solution Normal 3

Glucocard Expression Control In Vitro Solution 2

Glucocard Shine Control In Vitro Solution 2

Glucocard X-Sensor Control In Vitro SolutionNormal

3

GlucoCom Control In Vitro Liquid High , Normal 3

glucose control in vitro solution 2

glucose control in vitro solution normal 3

GNP Easy Touch Cont High/Low In Vitro Solution 2

In Touch Glucose Control In Vitro Solution 2

Infinity Control In Vitro Solution High , Low , Normal

3

Infinity Voice In Vitro Liquid Normal 3

Liberty Glucose Control In Vitro Liquid Normal 3

Liberty Glucose Control In Vitro Solution High , Normal

3

Liberty Glucose Control Mid In Vitro Solution 2

MediSense Glucose Ketone Contr In Vitro Liquid 2

Medisense Hi/Mid/Low Control In Vitro Liquid 2

Medisense High/Low Control In Vitro Liquid 2

Medisense Mid Control In Vitro Liquid 2

Microdot Control High/Low In Vitro Solution 2

MyGlucoHealth Control In Vitro Solution 2

Neutek 2Tek Control In Vitro Solution 2

Nova Max Plus Glu/Ket Control In Vitro Liquid 2

On Call Express Glucose Contr In Vitro Solution 2

On Call Plus Glucose Control In Vitro Solution 2

On Call Vivid Glucose Control In Vitro Solution 2

OneTouch Ultra Control In Vitro Solution 2

OneTouch Verio In Vitro Solution , High 2

OptumRx Glucose Control In Vitro Solution 2

PocketChem EZ Control In Vitro Solution 2


99


Precision Glucose Control In Vitro Liquid 2

Precision Glucose Control Soln In Vitro Solution 2

Precision Glucose Ketone Contr In Vitro Liquid 2

Precision Glucose/Ketone Contr In Vitro Liquid 2

Prodigy Control Solution In Vitro Solution High , Low

3

QuickTek Control Solution In Vitro Liquid 2

Quintet Control High/Normal In Vitro Solution 2

RefuAH Plus Glucose Control In Vitro Solution 2

Rightest GC300 Control In Vitro Liquid High , Normal

3

Smartest Control Medium In Vitro Solution 2

Solartek Glucose Control In Vitro Liquid 2

Solus V2 Control In Vitro Solution High , Low 3

supreme ii high/low control in vitro liquid 2

SureStep Glucose Control In Vitro Solution 2

SureStep Pro High Glucose In Vitro Liquid 3

SureStep Pro Low Glucose In Vitro Liquid 3

SureStep Pro Normal Glucose In Vitro Liquid 3

Tai Doc Control In Vitro Solution Normal 3

Telcare Glucose Control In Vitro Solution 2

True Metrix Level 1 In Vitro Solution Low 3

True Metrix Level 2 In Vitro Solution Normal 3

True Metrix Level 3 In Vitro Solution High 3

TrueControl Glucose Cont Lev 0 In Vitro Liquid 2

TrueControl Glucose Cont Lev 1 In Vitro Liquid 2

UltraTRAK PRO Control In Vitro Solution 2

UltraTRAK PRO Control In Vitro Solution Normal 3

UltraTRAK Ultimate Control In Vitro Solution 2

Unistrip Control In Vitro Solution High , Low 3

verasens glucose control in vitro liquid 2

Victory Control Level 1/2 In Vitro Solution 2

*Peak Flow Meters*** - Medical Supplies And Durable Medical Equipment

Aerogear Action Asthma Kit Kit 3

Airzone Peak Flow Meter Device 3

Assess Full Range Peak Meter Device 3

Assess Low Range Peak Meter Device 3

Assess Peak Flow Meter Device 3

Asthma Check Meter-Zone System Device 3

AsthmaMentOr Device 3

AsthmaPack I Kit 3

AsthmaPack II Kit 3


100


AsthmaPack III Kit 3

lung perform peak flow meter device 3

Microlife Digital Peak Flow Device 3

Mini Wright Peak Flow Meter Device 3

Peak Air Peak Flow Meter Device 3

peak flow meter universal rang device 3

Personal Best Full Range Device 3

Personal Best Low Range Device 3

Piko 1 Device 3

Pocket Peak Flow Meter Device 3

Pocketpeak Peak Flow Meter Device 3

TruZone Peak Flow Meter Device 3

*Spacer/Aerosol-Holding Chambers & Supplies*** - Medical Supplies And Durable Medical Equipment

AeroChamber Mini Chamber Device 2

AeroChamber MV 2

AeroChamber Plus Flo-Vu 2

AeroChamber Plus Flo-Vu Large 2

AeroChamber Plus Flo-Vu Medium 2

AeroChamber Plus Flo-Vu Small 2

AeroChamber Plus Flo-Vu w/Mask 2

AeroChamber Plus Flow VU 2

AeroChamber w/FLOWSIGnal 2

AeroChamber Z-Stat Plus 2

AeroChamber Z-Stat Plus Chambr 2

AeroChamber Z-Stat Plus/Large 2

AeroChamber Z-Stat Plus/Medium 2

AeroChamber Z-Stat Plus/Small 2

AeroVent Plus Device 2

Arial Chamber Device 2

breathe ease large device 2

breathe ease medium device 2

breathe ease small device 2

BreatheRite 2

BreatheRite Coll Spacer Adult 2

BreatheRite Coll Spacer Child 2

BreatheRite Coll Spacer Infant 2

BreatheRite Rigid Spacer/Mask 2

BreatheRite Spacer Neonate 2

BreatheRite Spacer Small Child 2

BreatheRite/Large Mask 2

BreatheRite/Medium Mask 2


101


BreatheRite/Small Mask 2

Clever Choice Holding Chamber Device 2

Compact Space Chamber Device 2

Compact Space Chamber/Lg Mask Device 2

Compact Space Chamber/Med Mask Device 2

Compact Space Chamber/Sm Mask Device 2

EasiVent 2

EasiVent Mask Large 2

EasiVent Mask Medium 2

EasiVent Mask Small 2

Flexichamber Adult Mask/Small 2

Flexichamber Child Mask/Large 2

Flexichamber Child Mask/Small 2

Flexichamber Device 2

InspiraChamber/Large Device 2

InspiraChamber/Medium Device 2

InspiraChamber/Mouthpiece Device 2

InspiraChamber/Small Device 2

Inspirease 2

LiteAire Device 2

Microchamber 2

Microspacer 2

OptiChamber Advantage-Lg Mask 2

OptiChamber Advantage-Med Mask 2

OptiChamber Advantage-Sm Mask 2

OptiChamber Diamond 2

OptiChamber Diamond-Lg Mask Device 2

OptiChamber Diamond-Md Mask 2

OptiChamber Diamond-Sm Mask 2

OptiChamber Face Mask-Large 2

OptiChamber Face Mask-Medium 2

OptiChamber Face Mask-Small 2

OptiHaler 2

OptiHaler Device 2

Pocket Chamber Device 2

Pocket Spacer Device 2

pro comfort spacer adult 2

pro comfort spacer child 2

RiteFlo Device 2

valved holding chamber device 2

Vortex Valved Holding Chamber Device 2

Watchhaler Device 2


102


*Melanocortin Receptor Agonists*** - Drugs For The Nervous System

*Melanocortin Receptor Agonists*** - Drugs For The Nervous System

Vyleesi Subcutaneous Solution Auto-Injector 1.75 MG/0.3ML

3 Female Only; QL

*Migraine Products* - Drugs For The Nervous System

*Ergot Combinations*** - Drugs For Migraine Headaches

ergotamine-caffeine oral tablet 1-100 mg 1

Migergot Rectal Suppository 2-100 MG 1

*Migraine Products - Nsaids*** - Drugs For Migraine Headaches

Cambia Oral Packet 50 MG 3 QL

*Migraine Products*** - Drugs For Migraine Headaches

dihydroergotamine mesylate injection solution 1 mg/ml 1

dihydroergotamine mesylate nasal solution 4 mg/ml 1 QL

Ergomar Sublingual Tablet Sublingual 2 MG 3

*Selective Serotonin Agonists 5-Ht(1)*** - Drugs For Migraine Headaches

almotriptan malate oral tablet 12.5 mg, 6.25 mg 1 QL

eletriptan hydrobromide oral tablet 20 mg, 40 mg 1 QL

frovatriptan succinate oral tablet 2.5 mg 1 QL

naratriptan hcl oral tablet 1 mg, 2.5 mg 1 QL

Onzetra Xsail Nasal Exhaler Powder 11 MG/NOSEPC

3

Relpax Oral Tablet 40 MG 3 QL

rizatriptan benzoate oral tablet 10 mg, 5 mg 1 QL

rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg

1 QL

sumatriptan nasal solution 20 mg/act, 5 mg/act 1 QL

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg

1 QL

sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml

1 QL

sumatriptan succinate subcutaneous solution 6 mg/0.5ml

1 QL

sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml

1 QL

sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml

1 QL

Zembrace SymTouch Subcutaneous Solution Auto-Injector 3 MG/0.5ML

3

zolmitriptan oral tablet 2.5 mg, 5 mg 1 QL


103


zolmitriptan oral tablet dispersible 2.5 mg, 5 mg 1 QL

Zomig Nasal Solution 2.5 MG, 5 MG 3 QL

*Minerals & Electrolytes* - Drugs For Nutrition

*Calcium Combinations*** - Drugs For Nutrition

calcium-folic acid plus d oral wafer 1342-1 mg 3

*Fluoride Combinations*** - Drugs For Nutrition

Floriva Oral Liquid 0.25-400 MG-UNIT/ML 3

*Fluoride*** - Drugs For Nutrition

Fluorabon Oral Solution 0.55 (0.25 F) MG/0.6ML 3

*Iodine Products*** - Drugs For Nutrition

iodine strong oral solution 5 % 1

*Magnesium Combinations*** - Drugs For Nutrition

MagneBind 400 Oral Tablet 400-200-1 MG 3

*Phosphate*** - Drugs For Nutrition

K-Phos Oral Tablet 500 MG 3

Phospha 250 Neutral Oral Tablet 155-852-130 MG 1

phosphorous oral tablet 155-852-130 mg 1

Phospho-Trin 250 Neutral Oral Tablet 155-852-130 MG

1

virt-phos 250 neutral oral tablet 155-852-130 mg 1

*Potassium Combinations*** - Drugs For Nutrition

Effer-K Oral Tablet Effervescent 10 MEQ, 20 MEQ 3

pot bicarb-pot chloride oral tablet effervescent 25 meq 1

*Potassium*** - Drugs For Nutrition

Effer-K Oral Tablet Effervescent 25 MEQ 1

Klor-Con 10 Oral Tablet Extended Release 10 MEQ 1

Klor-Con M10 Oral Tablet Extended Release 10 MEQ

1


1


1

Klor-Con Oral Packet 20 MEQ 1

Klor-Con Oral Tablet Extended Release 8 MEQ 1

Klor-Con Sprinkle Oral Capsule Extended Release10 MEQ, 8 MEQ

1

Klor-Con/EF Oral Tablet Effervescent 25 MEQ 1

K-Prime Oral Tablet Effervescent 25 MEQ 1

potassium bicarbonate oral tablet effervescent 25 meq 1

potassium chloride crys er oral tablet extended release 10 meq, 20 meq

1

potassium chloride er oral capsule extended release10 meq, 8 meq

1


104


potassium chloride er oral tablet extended release 10 meq, 8 meq

1

potassium chloride oral packet 20 meq 1

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

1

*Zinc*** - Drugs For Nutrition

Galzin Oral Capsule 25 MG, 50 MG 3

*Mixed Allergenic Extracts*** - Biological Agents

*Mixed Allergenic Extracts*** - Biological Agents

Odactra Sublingual Tablet Sublingual 12 SQ-HDM 3QL; Age Restriction Applies (Min 18 Years and Max 65 Years)

Oralair Sublingual Tablet Sublingual 300 IR 3QL; Age Restriction Applies (Min 10 Years and Max 65 Years)

*Monobactams*** - Drugs For Infections

*Monobactams*** - Drugs For Infections

Cayston Inhalation Solution Reconstituted 75 MG 3 QL

*Mouth/Throat/Dental Agents* - Drugs For The Mouth And Throat

*Anesthetics Topical Oral*** - Drugs For The Mouth And Throat

lidocaine hcl mouth/throat solution 4 % 1

Topex Topical Anesthetic Mouth/Throat Aerosol 20 %

1

*Anti-Infectives - Throat*** - Drugs For The Mouth And Throat

clotrimazole mouth/throat lozenge 10 mg 1

clotrimazole mouth/throat troche 10 mg 1

nystatin mouth/throat suspension 100000 unit/ml 1

Oravig Buccal Tablet 50 MG 3

*Antiseptic Combinations - Mouth/Throat*** - Drugs For The Mouth And Throat

Debacterol Mouth/Throat Solution 30-50 % 3

*Antiseptics - Mouth/Throat*** - Drugs For The Mouth And Throat

chlorhexidine gluconate mouth/throat solution 0.12 % 1

Paroex Mouth/Throat Solution 0.12 % 1

Periogard Mouth/Throat Solution 0.12 % 1

*Protectants - Mouth/Throat*** - Drugs For The Mouth And Throat

Gelclair Mouth/Throat Gel 2

Orafate Mouth/Throat Paste 10 % 3

ProThelial Mouth/Throat Paste 10 % 3

*Saliva Stimulants*** - Drugs For The Mouth And Throat

cevimeline hcl oral capsule 30 mg 1


105


pilocarpine hcl oral tablet 5 mg, 7.5 mg 1

*Steroids - Mouth/Throat*** - Drugs For The Mouth And Throat

Oralone Mouth/Throat Paste 0.1 % 1

triamcinolone acetonide mouth/throat paste 0.1 % 1

*Multiple Sclerosis Agents - Antimetabolites*** - Drugs For The Nervous System

*Multiple Sclerosis Agents - Antimetabolites*** - Drugs For The Nervous System

Mavenclad (10 Tabs) Oral Tablet Therapy Pack 10 MG

3 PA


3 PA


3 PA


3 PA


3 PA


3 PA


3 PA

*Multivitamins* - Drugs For Nutrition

*Prenatal Mv & Min W/Fe-Fa*** - Drugs For Nutrition

Atabex EC Oral Tablet Delayed Release 29-1 MG 3

Atabex OB Oral Tablet 29-1 MG 3

Bal-Care DHA Oral 27-1 & 430 MG 3

CitraNatal Bloom Oral Tablet 90-1 MG 3

CitraNatal Rx Oral Tablet 27-1 MG 3

c-nate dha oral capsule 28-1-200 mg 3

completenate oral tablet chewable 29-1 mg 3

Co-Natal FA Oral Tablet 3

Concept DHA Oral Capsule 53.5-38-1 MG 3

Concept OB Oral Capsule 130-92.4-1 MG 2

Duet DHA 400 Oral 25-1 & 400 MG 3

Duet DHA Balanced Oral 25-1 & 267 MG 3

Elite-OB Oral Tablet 50-1.25 MG 1

EnBrace HR Oral Capsule 3

Folivane-OB Oral Capsule 130-92.4-1 MG 3

Marnatal-F Oral Capsule 60-1 MG 3

m-natal plus oral tablet 27-1 mg 3

M-Vit Oral Tablet 3

Mynatal Advance Oral Tablet 3


106


Mynatal Oral Capsule 3

Mynatal Oral Tablet 90-1 MG 3

mynatal plus oral tablet 3

mynatal-z oral tablet 3

mynate 90 plus oral tablet extended release 3

NataChew Oral Tablet Chewable 28-1 MG 3

Natalvit Oral Tablet 3

NeoNatal Plus Oral Tablet 27-1 MG 3

Nestabs DHA Oral 32-1 MG 3

Nestabs Oral Tablet 32-1 MG 3

Niva-Plus Oral Tablet 27-1 MG 3

OB Complete One Oral Capsule 50-1-476 MG 3

OB Complete Oral Tablet 50-1.25 MG 3

OB Complete Petite Oral Capsule 35-5-1-200 MG 3

OB Complete Premier Oral Tablet 30-20-1 MG 3

OB Complete/DHA Oral Capsule 30-10-1-200 MG 3

Obstetrix DHA Oral 29-1 & 387 MG 3

Obstetrix EC Oral Tablet 29-1 MG 3

Obtrex DHA Oral 29-1 & 387 MG 3

Obtrex Oral Tablet 3

O-Cal Prenatal Oral Tablet 3

pnv folic acid + iron oral tablet 27-1 mg 3

pnv prenatal plus multivit+dha oral 27-1 & 312 mg 1

pnv prenatal plus multivitamin oral tablet 27-1 mg 3

pnv tabs 29-1 oral tablet 29-1 mg 3

pnv-omega oral capsule 28-0.6-0.4-340 mg 3

pnv-select oral tablet 27-0.6-0.4 mg 1

prena1 pearl oral capsule extended release 30-1.4-200 mg

3

prenatal 19 oral tablet 1

prenatal 19 oral tablet 29-1 mg 3

prenatal 19 oral tablet chewable 1

prenatal 19 oral tablet chewable 29-1 mg 3

prenatal oral tablet 27-1 mg 3

prenatal plus iron oral tablet 29-1 mg 3

prenatal vitamin plus low iron oral tablet 27-1 mg 3

Prenatal-U Oral Capsule 106.5-1 MG 3

Prenate Elite Oral Tablet 20-0.6-0.4 MG 3

preplus oral tablet 27-1 mg 3

pretab oral tablet 29-1 mg 3

PrimaCare Oral Capsule 30-1-470 MG 3

Provida OB Oral Capsule 20-20-1.25 MG 3


107


relnate dha oral capsule 28-1-200 mg 3

Select-OB Oral Tablet Chewable 29-0.6-0.4 MG, 29-1 MG

3

se-natal 19 oral tablet 29-1 mg 1

se-natal 19 oral tablet chewable 29-1 mg 3

Taron-C DHA Oral Capsule 53.5-38-1 MG 3

thrivite rx oral tablet 29-1 mg 3

TriCare Oral Tablet 3

TriCare Prenatal DHA ONE Oral Capsule 27-1-500 MG

3

trinatal rx 1 oral tablet 60-1 mg 3

tri-tabs dha oral 32-1 mg 3

Vinate Care Oral Tablet Chewable 40-1 MG 1

Vinate II Oral Tablet 29-1 MG 3

Vinate M Oral Tablet 27-1 MG 3

Vinate One Oral Tablet 60-1 MG 3

virt-c dha oral capsule 53.5-38-1 mg 3

virt-nate dha oral capsule 28-1-200 mg 3

virt-pn plus oral capsule 28-0.6-0.4-340 mg 3

Vitafol-OB Oral Tablet 3

VitaPearl Oral Capsule Extended Release 30-1.4-200 MG

3

Viva DHA Oral Capsule 28-1-200 MG 3

vol-plus oral tablet 27-1 mg 3

vol-tab rx oral tablet 29-1 mg 3

vp-heme ob + dha oral 28-6-1 & 203 mg 3

Zatean-Pn Plus Oral Capsule 28-0.6-0.4-340 MG 3

*Prenatal Mv & Min W/Fe-Fa-Ca-Omega 3 Fish Oil*** - Drugs For Nutrition

complete natal dha oral 29-1-200 & 250 mg 3

PR Natal 400 ec Oral 29-1-200 & 400 MG (DR) 3

PR Natal 400 Oral 29-1-200 & 400 MG 3

PR Natal 430 ec Oral 29-1-200 & 430 MG (DR) 3

PR Natal 430 Oral 29-1-200 & 430 MG 3

Triveen-Duo DHA Oral 29-1-200 & 400 MG 3

*Prenatal Mv & Min W/Fe-Fa-Dha*** - Drugs For Nutrition

CitraNatal 90 DHA Oral 90-1 & 300 MG 3

CitraNatal Assure Oral 35-1 & 300 MG 3

CitraNatal Bloom DHA Oral 90-1 & 300 MG 3

CitraNatal DHA Oral 27-1 & 250 MG 3

CitraNatal Harmony Oral Capsule 27-1-260 MG 3

Nestabs One Oral Capsule 38-1-225 MG 3


108


Obstetrix One Oral Capsule 38-1-225 MG 3

pnv-dha oral capsule 27-0.6-0.4-300 mg 1

pnv-dha+docusate oral capsule 27-1.25-300 mg 3

prena 1 true oral 30-1.4 & 300 mg 3

prenaissance oral capsule 29-1.25-325 mg 3

prenaissance plus oral capsule 28-1-250 mg 3

Prenatal + DHA Oral Therapy Pack 27-1 & 250 MG 3

Prenate DHA Oral Capsule 18-0.6-0.4-300 MG 3

Prenate Enhance Oral Capsule 28-0.6-0.4-400 MG 3

Prenate Essential Oral Capsule 18-0.6-0.4-300 MG 3

Prenate Mini Oral Capsule 18-0.6-0.4-350 MG 3

Prenate Pixie Oral Capsule 10-0.6-0.4-200 MG 3

Prenate Restore Oral Capsule 27-0.6-0.4-400 MG 3

R-Natal OB Oral Capsule 20-1-320 MG 3

Select-OB+DHA Oral 29-1 & 250 MG 3

Taron-Prex Oral Capsule 30-1.2-265 MG 3

tristart dha oral capsule 31-0.6-0.4-200 mg 3

virt-pn dha oral capsule 27-0.6-0.4-300 mg 3

Vitafol Ultra Oral Capsule 29-0.6-0.4-200 MG 3

Vitafol-OB+DHA Oral 65-1 & 250 MG 3

Vitafol-One Oral Capsule 29-1-200 MG 3

VitaTrue Oral 30-1.4 & 300 MG 3

Zatean-Pn DHA Oral Capsule 27-0.6-0.4-300 MG 3

*Prenatal Mv & Minerals W/Fa*** - Drugs For Nutrition

Prenate Oral Tablet Chewable 0.6-0.4 MG 3

*Prenatal Vitamins*** - Drugs For Nutrition

prena1 oral tablet chewable 1.4 mg 3

VitaMedMD RediChew Rx Oral Tablet Chewable 1.4 MG

3

*Musculoskeletal Therapy Agents* - Drugs For Muscles, Ligaments, Tendons, And Bones

*Central Muscle Relaxants*** - Drugs For Muscles, Ligaments, Tendons, And Bones

baclofen oral tablet 10 mg, 20 mg 1

carisoprodol oral tablet 250 mg, 350 mg 1 QL

chlorzoxazone oral tablet 500 mg 1

cyclobenzaprine hcl er oral capsule extended release 24 hour 15 mg, 30 mg

1

cyclobenzaprine hcl oral tablet 10 mg, 5 mg, 7.5 mg 1

Lorzone Oral Tablet 375 MG, 750 MG 1

metaxalone oral tablet 400 mg, 800 mg 1

methocarbamol oral tablet 500 mg, 750 mg 1


109


orphenadrine citrate er oral tablet extended release 12 hour 100 mg

1

Ozobax Oral Solution 5 MG/5ML 3Age Restriction Applies (Max 11 Years)

tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg 1

tizanidine hcl oral tablet 2 mg, 4 mg 1

*Direct Muscle Relaxants*** - Drugs For Muscles, Ligaments, Tendons, And Bones

dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg 1

*Muscle Relaxant Combinations*** - Drugs For Muscles, Ligaments, Tendons, And Bones

carisoprodol-aspirin oral tablet 200-325 mg 1 QL

carisoprodol-aspirin-codeine oral tablet 200-325-16 mg


*Nasal Agents - Systemic And Topical* - Drugs For The Nose

*Antihistamine-Steroid*** - Allergy

azelastine-fluticasone nasal suspension 137-50 mcg/act

1 QL

*Nasal Anticholinergics*** - Allergy

ipratropium bromide nasal solution 0.03 %, 0.06 % 1 QL

*Nasal Antihistamines*** - Allergy

azelastine hcl nasal solution 0.1 %, 0.15 %, 137 mcg/spray

1 QL

olopatadine hcl nasal solution 0.6 % 1

*Nasal Steroids*** - Allergy

Beconase AQ Nasal Suspension 42 MCG/SPRAY 3 QL

flunisolide nasal solution 25 mcg/act (0.025%) 1

fluticasone propionate nasal suspension 50 mcg/act 1

mometasone furoate nasal suspension 50 mcg/act 1 QL

Omnaris Nasal Suspension 50 MCG/ACT 3 QL

Qnasl Childrens Nasal Aerosol Solution 40 MCG/ACT

3 QL

Qnasl Nasal Aerosol Solution 80 MCG/ACT 3 QL

Zetonna Nasal Aerosol Solution 37 MCG/ACT 3QL; Age Restriction Applies (Min 12 Years)

*Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb*** - Drugs For The Heart

*Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb*** - Drugs For The Heart

Entresto Oral Tablet 24-26 MG, 49-51 MG, 97-103 MG

3


110


*Neuromuscular Agents* - Drugs For Nerves And Muscles

*Benzathiazoles*** - Drugs For Nerves And Muscles

riluzole oral tablet 50 mg 1

Tiglutik Oral Suspension 50 MG/10ML 3

*Ophthalmic Agents* - Drugs For The Eye

*Alpha Adrenergic Agonist & Carbonic Anhydrase Inhib Comb*** - Drugs For Glaucoma

Simbrinza Ophthalmic Suspension 1-0.2 % 3

*Artificial Tear Inserts*** - Drugs For The Eye

Lacrisert Ophthalmic Insert 5 MG 3

*Beta-Blockers - Ophthalmic Combinations*** - Drugs For Glaucoma

Combigan Ophthalmic Solution 0.2-0.5 % 3

dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml

1

*Beta-Blockers - Ophthalmic*** - Drugs For Glaucoma

betaxolol hcl ophthalmic solution 0.5 % 1

Betimol Ophthalmic Solution 0.25 %, 0.5 % 3

Betoptic-S Ophthalmic Suspension 0.25 % 3

carteolol hcl ophthalmic solution 1 % 1

levobunolol hcl ophthalmic solution 0.5 % 1

timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 %

1

timolol maleate ophthalmic solution 0.25 %, 0.5 %, 0.5 % (daily)

1

Timoptic Ocudose Ophthalmic Solution 0.25 %, 0.5 %

3

*Cycloplegic Mydriatic Combinations*** - Drugs For The Eye

Cyclomydril Ophthalmic Solution 0.2-1 % 1

*Cycloplegic Mydriatics*** - Drugs For The Eye

Altafrin Ophthalmic Solution 10 %, 2.5 % 1

atropine sulfate ophthalmic ointment 1 % 1

atropine sulfate ophthalmic solution 1 % 1

cyclopentolate hcl ophthalmic solution 0.5 %, 1 %, 2 % 1

Homatropaire Ophthalmic Solution 5 % 1

Isopto Atropine Ophthalmic Solution 1 % 1

phenylephrine hcl ophthalmic solution 10 %, 2.5 % 1

tropicamide ophthalmic solution 0.5 %, 1 % 1


111


*Miotics - Cholinesterase Inhibitors*** - Drugs For Glaucoma

Phospholine Iodide Ophthalmic Solution Reconstituted 0.125 %

2

*Miotics - Direct Acting*** - Drugs For Glaucoma

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % 1

*Ophthalmic Antiallergic*** - Drugs For Itchy Eye

Alocril Ophthalmic Solution 2 % 2

Alomide Ophthalmic Solution 0.1 % 2

azelastine hcl ophthalmic solution 0.05 % 1

Bepreve Ophthalmic Solution 1.5 % 2

cromolyn sodium ophthalmic solution 4 % 1

epinastine hcl ophthalmic solution 0.05 % 1

Lastacaft Ophthalmic Solution 0.25 % 3

olopatadine hcl ophthalmic solution 0.1 %, 0.2 % 1

Pazeo Ophthalmic Solution 0.7 % 3

Zerviate Ophthalmic Solution 0.24 % 3

*Ophthalmic Antibiotics*** - Anti-Infective/Anti-Inflammatories

AzaSite Ophthalmic Solution 1 % 3

bacitracin ophthalmic ointment 500 unit/gm 1

Besivance Ophthalmic Suspension 0.6 % 3

Ciloxan Ophthalmic Ointment 0.3 % 3

ciprofloxacin hcl ophthalmic solution 0.3 % 1

erythromycin ophthalmic ointment 5 mg/gm 1

gatifloxacin ophthalmic solution 0.5 % 1

Gentak Ophthalmic Ointment 0.3 % 1

gentamicin sulfate ophthalmic solution 0.3 % 1

levofloxacin ophthalmic solution 0.5 % 1

moxifloxacin hcl (2x day) ophthalmic solution 0.5 % 1

moxifloxacin hcl ophthalmic solution 0.5 % 1

ofloxacin ophthalmic solution 0.3 % 1

tobramycin ophthalmic solution 0.3 % 1

Tobrex Ophthalmic Ointment 0.3 % 3

*Ophthalmic Antifungal*** - Drugs For The Eye

Natacyn Ophthalmic Suspension 5 % 3

*Ophthalmic Anti-Infective Combinations*** - Anti-Infective/Anti-Inflammatories

ak-poly-bac ophthalmic ointment 500-10000 unit/gm 1

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

1

neomycin-bacitracin zn-polymyx ophthalmic ointment3.5-400-10000 , 5-400-10000

1


112


neomycin-polymyxin-gramicidin ophthalmic solution1.75-10000-.025

1

Neo-Polycin Ophthalmic Ointment 3.5-400-10000 1

Polycin Ophthalmic Ointment 500-10000 UNIT/GM 1

polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-%

1

*Ophthalmic Antiseptics*** - Anti-Infective/Anti-Inflammatories

Betadine Ophthalmic Prep Ophthalmic Solution 5 %

3

*Ophthalmic Antivirals*** - Anti-Infective/Anti-Inflammatories

trifluridine ophthalmic solution 1 % 1

Zirgan Ophthalmic Gel 0.15 % 3

*Ophthalmic Carbonic Anhydrase Inhibitors*** - Drugs For Glaucoma

Azopt Ophthalmic Suspension 1 % 3

dorzolamide hcl ophthalmic solution 2 % 1

*Ophthalmic Immunomodulators*** - Anti-Infective/Anti-Inflammatories

Restasis Ophthalmic Emulsion 0.05 % 2 QL

*Ophthalmic Local Anesthetics*** - Drugs For The Eye

Akten Ophthalmic Gel 3.5 % 3

Altacaine Ophthalmic Solution 0.5 % 1

proparacaine hcl ophthalmic solution 0.5 % 1

tetracaine hcl ophthalmic solution 0.5 % 1

*Ophthalmic Nonsteroidal Anti-Inflammatory Agents*** - Anti-Infective/Anti-Inflammatories

Acuvail Ophthalmic Solution 0.45 % 3

bromfenac sodium (once-daily) ophthalmic solution0.09 %


BromSite Ophthalmic Solution 0.075 % 3Age Restriction Applies (Min 18 Years)

diclofenac sodium ophthalmic solution 0.1 % 1

flurbiprofen sodium ophthalmic solution 0.03 % 1

Ilevro Ophthalmic Suspension 0.3 % 3Age Restriction Applies (Min 10 Years)

ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 %

1

Nevanac Ophthalmic Suspension 0.1 % 3Age Restriction Applies (Min 10 Years)

Prolensa Ophthalmic Solution 0.07 % 3Age Restriction Applies (Min 18 Years)


113


*Ophthalmic Selective Alpha Adrenergic Agonists*** - Drugs For Glaucoma

Alphagan P Ophthalmic Solution 0.1 % 2

apraclonidine hcl ophthalmic solution 0.5 % 1

brimonidine tartrate ophthalmic solution 0.15 %, 0.2 % 1

Iopidine Ophthalmic Solution 1 % 3

*Ophthalmic Steroid Combinations*** - Anti-Infective/Anti-Inflammatories

bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %

1

Blephamide Ophthalmic Suspension 10-0.2 % 3

Blephamide S.O.P. Ophthalmic Ointment 10-0.2 % 3

neomycin-polymyxin-dexameth ophthalmic ointment3.5-10000-0.1

1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1

1

Neo-Polycin HC Ophthalmic Ointment 1 % 1

Pred-G Ophthalmic Suspension 0.3-1 % 2

Pred-G S.O.P. Ophthalmic Ointment 0.3-0.6 % 2

sulfacetamide-prednisolone ophthalmic solution 10-0.23 %

1

TobraDex Ophthalmic Ointment 0.3-0.1 % 2

TobraDex ST Ophthalmic Suspension 0.3-0.05 % 3

tobramycin-dexamethasone ophthalmic suspension0.3-0.1 %

1

Zylet Ophthalmic Suspension 0.5-0.3 % 3

*Ophthalmic Steroids*** - Anti-Infective/Anti-Inflammatories

Alrex Ophthalmic Suspension 0.2 % 2

dexamethasone sodium phosphate ophthalmic solution 0.1 %

1

Durezol Ophthalmic Emulsion 0.05 % 3

Flarex Ophthalmic Suspension 0.1 % 2

fluorometholone ophthalmic suspension 0.1 % 1

FML Forte Ophthalmic Suspension 0.25 % 2

FML Ophthalmic Ointment 0.1 % 2

Inveltys Ophthalmic Suspension 1 % 3

Lotemax Ophthalmic Gel 0.5 % 2

Lotemax Ophthalmic Ointment 0.5 % 2

Lotemax SM Ophthalmic Gel 0.38 % 3

loteprednol etabonate ophthalmic suspension 0.5 % 1

Maxidex Ophthalmic Suspension 0.1 % 3

Pred Mild Ophthalmic Suspension 0.12 % 3


114


prednisolone acetate ophthalmic suspension 1 % 1

prednisolone acetate p-f ophthalmic suspension 1 % 3

prednisolone sodium phosphate ophthalmic solution 1 %

1

*Ophthalmic Sulfonamides*** - Anti-Infective/Anti-Inflammatories

sulfacetamide sodium ophthalmic ointment 10 % 1

sulfacetamide sodium ophthalmic solution 10 % 1

*Ophthalmic Surgical Aids*** - Drugs For The Eye

Gelfilm Ophthalmic Film 3

*Ophthalmics - Cystinosis Agents** - Drugs For The Eye

Cystaran Ophthalmic Solution 0.44 % 3

*Prostaglandins - Ophthalmic*** - Drugs For Glaucoma

bimatoprost ophthalmic solution 0.03 % 1

latanoprost ophthalmic solution 0.005 % 1

Lumigan Ophthalmic Solution 0.01 % 2 ST

Travatan Z Ophthalmic Solution 0.004 % 3 ST

Zioptan Ophthalmic Solution 0.0015 % 3 ST

*Orexin Receptor Antagonists*** - Drugs For The Nervous System

*Orexin Receptor Antagonists*** - Drugs For The Nervous System

Belsomra Oral Tablet 10 MG, 15 MG, 20 MG, 5 MG 3 QL

*Otic Agents* - Drugs For The Ear

*Otic Agents - Miscellaneous*** - Wax Removal

acetic acid otic solution 2 % 1

*Otic Anti-Infectives*** - Antibiotics

ciprofloxacin hcl otic solution 0.2 % 1

ofloxacin otic solution 0.3 % 1

*Otic Steroid-Anti-Infective Combinations*** - Anti-Infective/Anti-Inflammatories

Cipro HC Otic Suspension 0.2-1 % 3

Ciprodex Otic Suspension 0.3-0.1 % 2

neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1 1

neomycin-polymyxin-hc otic suspension 3.5-10000-1 1

Otovel Otic Solution 0.3-0.025 % 2

*Otic Steroids*** - Anti-Infective/Anti-Inflammatories

Flac Otic Oil 0.01 % 1

fluocinolone acetonide otic oil 0.01 % 1

hydrocortisone-acetic acid otic solution 1-2 % 1


115


*Oxaborole-Related Antifungals - Topical*** - Drugs For The Skin

*Oxaborole-Related Antifungals - Topical*** - Drugs For The Skin

Kerydin External Solution 5 % 3 ST

*Oxytocics* - Hormones

*Abortifacients/Cervical Ripening - Prostaglandins*** - Drugs For Women

Cervidil Vaginal Insert 10 MG 3

Prepidil Vaginal Gel 0.5 MG/3GM 3

Prostin E2 Vaginal Suppository 20 MG 3

*Oxytocics*** - Drugs For Women

Methergine Oral Tablet 0.2 MG 1

methylergonovine maleate oral tablet 0.2 mg 1

*Pa Endonuclease Inhibitors*** - Drugs For Infections

*Pa Endonuclease Inhibitors*** - Drugs For Infections

Xofluza (40 MG Dose) Oral Tablet Therapy Pack 2 x 20 MG

3 QL

Xofluza (80 MG Dose) Oral Tablet Therapy Pack 2 x 40 MG

3 QL

*Pcsk9 Inhibitors*** - Drugs For The Heart

*Pcsk9 Inhibitors*** - Drugs For The Heart

Praluent Subcutaneous Solution Auto-Injector 150 MG/ML, 75 MG/ML

2 PA; QL

Repatha Pushtronex System Subcutaneous Solution Cartridge 420 MG/3.5ML

2 PA; QL

Repatha Subcutaneous Solution Prefilled Syringe140 MG/ML

2 PA; QL

Repatha SureClick Subcutaneous Solution Auto-Injector 140 MG/ML

2 PA; QL

*Penicillins* - Drugs For Infections

*Aminopenicillins*** - Antibiotics

amoxicillin oral capsule 250 mg, 500 mg 1

amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml

1

amoxicillin oral tablet 500 mg, 875 mg 1

amoxicillin oral tablet chewable 125 mg, 250 mg 1

ampicillin oral capsule 500 mg 1

*Natural Penicillins*** - Antibiotics

penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml

1

penicillin v potassium oral tablet 250 mg, 500 mg 1


116


*Penicillin Combinations*** - Antibiotics

amoxicillin-pot clavulanate er oral tablet extended release 12 hour 1000-62.5 mg

1

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml

1

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

1

amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg

1

Augmentin Oral Suspension Reconstituted 125-31.25 MG/5ML

3

*Penicillinase-Resistant Penicillins*** - Antibiotics

dicloxacillin sodium oral capsule 250 mg, 500 mg 1

*Pharmaceutical Adjuvants*

*Antimicrobial Agents***

benzyl alcohol liquid 2

*Flavoring Agents***

benzaldehyde oral elixir 2

*Oral Vehicles***

cvs distilled water oral liquid 2

cvs purified water oral liquid 2

distillata distilled water oral liquid 2

distilled water oral liquid 2

Flavor Blend Oral Suspension 2

flavor plus oral liquid 2

flavor sweet oral syrup 2

flavor sweet-sf oral syrup 2

grape syrup oral syrup 3

MX-Sol Blend Oral Suspension 3

MX-Sol Blend SF Oral Suspension 3

MX-Sol Oral Syrup 3

MX-Sol SF Oral Syrup 3

MX-Sol Suspend Oral Suspension 3

Nice Distilled Water Oral Liquid 2

Ora-Blend Oral Suspension 2

Ora-Blend SF Oral Suspension 2

Oral Mix Oral Suspension 2

Oral Mix SF Oral Suspension 2

oral suspend oral liquid 2

oral suspending compound plus oral suspension 3

oral syrup oral syrup 2

oral syrup sf oral syrup 2


117


Ora-Plus Oral Liquid 2

Ora-Sweet Oral Syrup 2

Ora-Sweet SF Oral Syrup 2

PCCA Sweet-SF Oral Syrup 2

PCCA Syrup Vehicle Oral Syrup 3

PCCA-Plus Oral Suspension 3

purified water oral liquid 2

px purified water oral liquid 2

RA Crystal Lake Dist Water Oral Liquid 2

simple syrup oral syrup 2

sorbitol solution , 70 % 2

SuspendRx w/BitterBloc Sweet Oral Suspension 3

SuspendRx w/BitterBloc Unsweet Oral Suspension

3

suspension vehicle oral suspension 2

sweetening suspending compound oral syrup 3

Syrpalta (Red) Oral Syrup 2

syrpalta oral syrup , 85 % 2

SyrSpend SF Oral Liquid 2

syrup nf oral syrup 85 % 2

syrup vehicle oral syrup 2

syrup vehicle sf oral syrup 2

VersaFree Oral Syrup 2

VersaPlus Oral Syrup 2

*Pharmaceutical Excipients***

base x flakes 2

cocoa butter 2

Fattyblend 2

polypeg 2

spg supposi-base pellet 2

Supposiblend Pellet 2

Supposi-Plex R36 Pellet 2

Supposi-Plex V33 Pellet 2

Witepsol Pellet 2

Witepsol Wax 2

*Phosphatidylinositol 3-Kinase (Pi3k) Inhibitors*** - Drugs For Cancer

*Phosphatidylinositol 3-Kinase (Pi3k) Inhibitors*** - Drugs For Cancer

Copiktra Oral Capsule 15 MG, 25 MG 3 PA

Piqray (200 MG Daily Dose) Oral Tablet Therapy Pack 200 MG

3 PA


118


Piqray (250 MG Daily Dose) Oral Tablet Therapy Pack 200 & 50 MG

3 PA

Piqray (300 MG Daily Dose) Oral Tablet Therapy Pack 2 x 150 MG

3 PA

Zydelig Oral Tablet 100 MG, 150 MG 3 PA; QL

*Phosphodiesterase 4 (Pde4) Inhibitors - Topical*** - Drugs For The Skin

*Phosphodiesterase 4 (Pde4) Inhibitors - Topical*** - Drugs For The Skin

Eucrisa External Ointment 2 % 3

*Phosphodiesterase 4 (Pde4) Inhibitors*** - Drugs For Pain And Fever

*Phosphodiesterase 4 (Pde4) Inhibitors*** - Drugs For Pain And Fever

Otezla Oral Tablet 30 MG 2 PA; QL

Otezla Oral Tablet Therapy Pack 10 & 20 & 30 MG 2 PA; QL

*Pleuromutilins*** - Drugs For Infections

*Pleuromutilins*** - Drugs For Infections

Xenleta Oral Tablet 600 MG 3

*Poly (Adp-Ribose) Polymerase (Parp) Inhibitors** - Drugs For Cancer

*Poly (Adp-Ribose) Polymerase (Parp) Inhibitors** - Drugs For Cancer

Lynparza Oral Tablet 100 MG, 150 MG 3 PA; QL

Rubraca Oral Tablet 200 MG, 250 MG, 300 MG 3 PA; QL

Talzenna Oral Capsule 0.25 MG, 1 MG 3 PA

Zejula Oral Capsule 100 MG 3 PA; QL

*Poly (Adp-Ribose) Polymerase (Parp) Inhibitors*** - Drugs For Cancer

*Poly (Adp-Ribose) Polymerase (Parp) Inhibitors*** - Drugs For Cancer

Lynparza Oral Tablet 100 MG, 150 MG 3 PA; QL

Rubraca Oral Tablet 200 MG, 250 MG, 300 MG 3 PA; QL

Talzenna Oral Capsule 0.25 MG, 1 MG 3 PA

Zejula Oral Capsule 100 MG 3 PA; QL

*Postherpetic Neuralgia (Phn)/Neuropathic Pain Agents*** - Drugs For The Nervous System

*Postherpetic Neuralgia (Phn)/Neuropathic Pain Agents*** - Drugs For The Nervous System

Lyrica CR Oral Tablet Extended Release 24 Hour165 MG, 330 MG, 82.5 MG

3 QL

*Potassium Removing Agents*** - Drugs For Nutrition

*Potassium Removing Agents*** - Drugs For Nutrition

Kionex Oral Suspension 15 GM/60ML 1


119


Lokelma Oral Packet 10 GM, 5 GM 3

sodium polystyrene sulfonate oral powder 1

sodium polystyrene sulfonate oral suspension 15 gm/60ml

1

sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 gm/200ml

1

SPS Oral Suspension 15 GM/60ML 1

Veltassa Oral Packet 16.8 GM, 25.2 GM, 8.4 GM 3

*Prenatal Mv & Minerals W/Fa Without Iron*** - Drugs For Nutrition

*Prenatal Mv & Minerals W/Fa Without Iron*** - Drugs For Nutrition

Prenate Oral Tablet Chewable 0.6-0.4 MG 3

*Progestins* - Hormones

*Progestins*** - Drugs For Women

hydroxyprogesterone caproate intramuscular oil 250 mg/ml

1

medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg

1

megestrol acetate oral suspension 625 mg/5ml 1

norethindrone acetate oral tablet 5 mg 1

progesterone micronized oral capsule 100 mg, 200 mg 1

*Protease-Activated Receptor-1 (Par-1) Antagonists*** - Drugs For The Blood

*Protease-Activated Receptor-1 (Par-1) Antagonists*** - Drugs For The Blood

Zontivity Oral Tablet 2.08 MG 3 QL

*Psychotherapeutic And Neurological Agents - Misc.* - Drugs For The Nervous System

*Alcohol Deterrents*** - Drugs For The Nervous System

acamprosate calcium oral tablet delayed release 333 mg

1

disulfiram oral tablet 250 mg, 500 mg 1

*Anti-Cataplectic Agents*** - Drugs For Sleep Disorder

Xyrem Oral Solution 500 MG/ML 2 PA; QL

*Benzodiazepines & Tricyclic Agents*** - Drugs For Seizures /Personality Disorder/Nerve Pain

chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg

1

*Cholinomimetics - Ache Inhibitors*** - Drugs For Alzheimer's Disease

donepezil hcl oral tablet 10 mg, 5 mg 1 QL

donepezil hcl oral tablet dispersible 10 mg, 5 mg 1 QL


120


galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 mg

1 QL

galantamine hydrobromide oral solution 4 mg/ml 1

galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg

1

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

1 QL

rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr

1 QL

*Fibromyalgia Agent - Snris*** - Drugs For Seizures /Personality Disorder/Nerve Pain

Savella Oral Tablet 100 MG, 12.5 MG, 25 MG, 50 MG

2 QL

Savella Titration Pack Oral 12.5 & 25 & 50 MG 2 QL

*Movement Disorder Drug Therapy*** - Drugs For The Nervous System

Austedo Oral Tablet 12 MG, 6 MG, 9 MG 3 PA

Ingrezza Capsule Therapy Pack 40 & 80 MG Oral40 & 80 MG

3 PA; QL

Ingrezza Oral Capsule 40 MG, 80 MG 3 PA; QL

tetrabenazine oral tablet 12.5 mg, 25 mg 1 PA

Xenazine Oral Tablet 12.5 MG, 25 MG 3 PA

*Ms Agents - Pyrimidine Synthesis Inhibitors*** - Drugs For Multiple Sclerosis

Aubagio Oral Tablet 14 MG, 7 MG 2 PA; QL

*Multiple Sclerosis Agents - Interferons*** - Drugs For Multiple Sclerosis

Avonex Pen Intramuscular Auto-Injector Kit 30 MCG/0.5ML

2 PA; QL

Avonex Prefilled Intramuscular Prefilled Syringe Kit 30 MCG/0.5ML

2 PA; QL

Extavia Subcutaneous Kit 0.3 MG 3 PA; QL

Plegridy Starter Pack Subcutaneous Solution Pen-Injector 63 & 94 MCG/0.5ML

3 PA; QL

Plegridy Starter Pack Subcutaneous Solution Prefilled Syringe 63 & 94 MCG/0.5ML

3 PA; QL

Plegridy Subcutaneous Solution Pen-Injector 125 MCG/0.5ML

3 PA; QL

Plegridy Subcutaneous Solution Prefilled Syringe125 MCG/0.5ML

3 PA; QL

Rebif Rebidose Subcutaneous Solution Auto-Injector 22 MCG/0.5ML, 44 MCG/0.5ML

2 PA; QL

Rebif Rebidose Titration Pack Subcutaneous Solution Auto-Injector 6X8.8 & 6X22 MCG

2 PA; QL

Rebif Subcutaneous Solution Prefilled Syringe 22 MCG/0.5ML, 44 MCG/0.5ML

2 PA; QL


121


Rebif Titration Pack Subcutaneous Solution Prefilled Syringe 6X8.8 & 6X22 MCG

2 PA; QL

*Multiple Sclerosis Agents - Nrf2 Pathway Activators*** - Drugs For Multiple Sclerosis

Tecfidera Oral 120 & 240 MG 2 PA; QL

Tecfidera Oral Capsule Delayed Release 120 MG, 240 MG

2 PA; QL

Vumerity (Starter) Oral Capsule Delayed Release231 MG

3 PA

Vumerity Oral Capsule Delayed Release 231 MG 3 PA

*Multiple Sclerosis Agents - Potassium Channel Blockers*** - Drugs For Multiple Sclerosis

Ampyra Oral Tablet Extended Release 12 Hour 10 MG

3 PA; QL

dalfampridine er oral tablet extended release 12 hour10 mg

1 PA; QL

*Multiple Sclerosis Agents*** - Drugs For Multiple Sclerosis

Copaxone Subcutaneous Solution Prefilled Syringe 20 MG/ML, 40 MG/ML

2 PA; QL

glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml, 40 mg/ml

1 PA; QL

Glatopa Subcutaneous Solution Prefilled Syringe20 MG/ML, 40 MG/ML

1 PA; QL

*N-Methyl-D-Aspartate (Nmda) Receptor Antagonists*** - Drugs For Alzheimer's Disease

memantine hcl er oral capsule extended release 24 hour 14 mg, 21 mg, 28 mg, 7 mg

1 QL

memantine hcl oral solution 2 mg/ml 1

memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg, 5 mg

1 QL

*Phenothiazines & Tricyclic Agents*** - Drugs For Depression

perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg


*Postherpetic Neuralgia (Phn) Agents*** - Drugs For Seizures /Personality Disorder/Nerve Pain

Lyrica CR Oral Tablet Extended Release 24 Hour165 MG, 330 MG, 82.5 MG

3 QL

*Premenstrual Dysphoric Disorder (Pmdd) Agents - Ssris*** - Drugs For Depression

fluoxetine hcl (pmdd) oral tablet 10 mg, 20 mg 1

*Pseudobulbar Affect Agent Combinations*** - Drugs For Severe Mental Disorders

Nuedexta Oral Capsule 20-10 MG 3

*Psychotherapeutic And Neurological Agents - Misc.*** - Drugs For Severe Mental Disorders

ergoloid mesylates oral tablet 1 mg 1


122


pimozide oral tablet 1 mg, 2 mg 1

*Smoking Deterrents*** - Drugs For Depression

bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg

1

Chantix Continuing Month Pak Oral Tablet 1 MG 2

Chantix Oral Tablet 0.5 MG, 1 MG 2

Chantix Starting Month Pak Oral Tablet 0.5 MG X 11 & 1 MG X 42

2

*Sphingosine 1-Phosphate (S1p) Receptor Modulators*** - Drugs For Multiple Sclerosis

Gilenya Oral Capsule 0.25 MG, 0.5 MG 2 PA; QL

Mayzent Oral Tablet 0.25 MG, 2 MG 2 PA

Mayzent Starter Pack Oral Tablet Therapy Pack0.25 MG

2 PA

*Thienbenzodiazepines & Ssris*** - Drugs For Severe Mental Disorders

olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg


*Vasomotor Symptom Agents - Ssris*** - Drugs For The Nervous System

paroxetine mesylate oral capsule 7.5 mg 1 QL

*Pulmonary Fibrosis Agents - Kinase Inhibitors*** - Drugs For Cancer

*Pulmonary Fibrosis Agents - Kinase Inhibitors*** - Drugs For Cancer

Ofev Oral Capsule 100 MG, 150 MG 3 PA; QL

*Pulmonary Fibrosis Agents*** - Drugs For The Lungs

*Pulmonary Fibrosis Agents*** - Drugs For The Lungs

Esbriet Oral Capsule 267 MG 3 PA; QL

Esbriet Oral Tablet 267 MG, 801 MG 3 PA; QL

*Pulmonary Hypertension - Prostacyclin Receptor Agonist*** - Drugs For The Heart

*Pulmonary Hypertension - Prostacyclin Receptor Agonist*** - Drugs For The Heart

Uptravi Oral Tablet 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

3 PA; QL

Uptravi Oral Tablet Therapy Pack 200 & 800 MCG 3 PA; QL

*Respiratory Agents - Misc.* - Drugs For The Lungs

*Cftr Potentiators*** - Drugs For Cystic Fibrosis

Kalydeco Oral Packet 50 MG, 75 MG 2 PA; QL

Kalydeco Oral Tablet 150 MG 2 PA; QL

Kalydeco Packet 25 MG Oral 25 MG 2 PA; QL


123


*Hydrolytic Enzymes*** - Drugs For The Lungs

Pulmozyme Inhalation Solution 1 MG/ML 2

*Serotonin 1A Recept Agonist/Serotonin 2A Recept Antag*** - Drugs For The Nervous System

*Serotonin 1A Recept Agonist/Serotonin 2A Recept Antag*** - Drugs For The Nervous System

Addyi Oral Tablet 100 MG 3QL; Age Restriction Applies (Max 50 Years)

*Serotonin Modulators*** - Drugs For The Nervous System

*Serotonin Modulators*** - Drugs For The Nervous System

nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

1

trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg

1

Trintellix Oral Tablet 10 MG, 20 MG, 5 MG 2 QL

Viibryd Oral Tablet 10 MG, 20 MG, 40 MG 2 QL

Viibryd Starter Pack Oral Kit 10 & 20 MG 2 QL

*Sglt2 Inhibitor - Dpp-4 Inhibitor Combinations*** - Hormones

*Sglt2 Inhibitor - Dpp-4 Inhibitor Combinations*** - Hormones

Glyxambi Oral Tablet 10-5 MG, 25-5 MG 2 ST; QL

Qtern Oral Tablet 10-5 MG, 5-5 MG 2 ST; QL

*Sinus Node Inhibitors** - Drugs For The Heart

*Sinus Node Inhibitors** - Drugs For The Heart

Corlanor Oral Solution 5 MG/5ML 3Age Restriction Applies (Max 11 Years)

Corlanor Oral Tablet 5 MG, 7.5 MG 3 QL

*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb*** - Hormones

*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb*** - Hormones

Synjardy Oral Tablet 12.5-1000 MG, 12.5-500 MG, 5-1000 MG, 5-500 MG

2 ST; QL

Synjardy XR Oral Tablet Extended Release 24 Hour 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 MG

2 ST; QL

Xigduo XR Oral Tablet Extended Release 24 Hour10-1000 MG, 10-500 MG, 2.5-1000 MG, 5-1000 MG, 5-500 MG

2 ST; QL

*Spleen Tyrosine Kinase (Syk) Inhibitors*** - Drugs For The Blood

*Spleen Tyrosine Kinase (Syk) Inhibitors*** - Drugs For The Blood

Tavalisse Oral Tablet 100 MG, 150 MG 3 PA


124


*Steroids - Mouth/Throat/Dental*** - Drugs For The Mouth And Throat

*Steroids - Mouth/Throat/Dental*** - Drugs For The Mouth And Throat

Oralone Mouth/Throat Paste 0.1 % 1

triamcinolone acetonide mouth/throat paste 0.1 % 1

*Sulfonamides* - Drugs For Infections

*Sulfonamides*** - Antibiotics

sulfadiazine oral tablet 500 mg 1

*Tetracyclines* - Drugs For Infections

*Tetracyclines*** - Antibiotics

avidoxy oral tablet 100 mg 1

demeclocycline hcl oral tablet 150 mg, 300 mg 1

Doryx Oral Tablet Delayed Release 200 MG 3

doxycycline hyclate oral capsule 100 mg, 50 mg 1

doxycycline hyclate oral tablet 100 mg, 150 mg, 20 mg, 50 mg, 75 mg

1

doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 200 mg, 50 mg, 75 mg

1

doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 75 mg

1

doxycycline monohydrate oral suspension reconstituted 25 mg/5ml

1

doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg

1

minocycline hcl er oral tablet extended release 24 hour 115 mg, 65 mg

1

minocycline hcl oral capsule 100 mg, 50 mg, 75 mg 1

minocycline hcl oral tablet 100 mg, 50 mg, 75 mg 1

Minolira Oral Tablet Extended Release 24 Hour 105 MG, 135 MG

3

Mondoxyne NL Oral Capsule 100 MG, 75 MG 1

Morgidox Oral Capsule 100 MG 1

Okebo Oral Capsule 75 MG 1

tetracycline hcl oral capsule 250 mg, 500 mg 1

Vibramycin Oral Syrup 50 MG/5ML 3

Ximino Oral Capsule Extended Release 24 Hour135 MG, 45 MG, 90 MG

3

*Thyroid Agents* - Hormones

*Antithyroid Agents*** - Drugs For Thyroid

methimazole oral tablet 10 mg, 5 mg 1

propylthiouracil oral tablet 50 mg 1

*Thyroid Hormones*** - Drugs For Thyroid

Armour Thyroid Oral Tablet 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG

3


125


Cytomel Oral Tablet 25 MCG, 5 MCG, 50 MCG 3

Euthyrox Oral Tablet 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

1

Levo-T Oral Tablet 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

1

levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

1

Levoxyl Oral Tablet 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

1

liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg 1

Nature-Throid Oral Tablet 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

1

Synthroid Oral Tablet 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

3

Tirosint Oral Capsule 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

3

Tirosint-SOL Oral Solution 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 MCG/ML, 25 MCG/ML, 50 MCG/ML, 75 MCG/ML, 88 MCG/ML

3

Unithroid Oral Tablet 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

1

Westhroid Oral Tablet 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG

1

WP Thyroid Oral Tablet 113.75 MG, 130 MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

1

*Topical Anesthetic Gases*** - Drugs For The Skin

*Topical Anesthetic Gases*** - Drugs For The Skin

ethyl chloride external aerosol 1

Gebauers Pain Ease External Aerosol 3

Gebauers Spray and Stretch External Aerosol 3

*Toxoids* - Biological Agents

*Toxoid Combinations*** - Vaccines

Adacel Intramuscular Suspension 5-2-15.5 LF-MCG/0.5

3

Boostrix Intramuscular Suspension 5-2.5-18.5 LF-MCG/0.5

3

Daptacel Intramuscular Suspension 23-15-5 3Age Restriction Applies (Max 18 Years)


126


diphtheria-tetanus toxoids dt intramuscular suspension25-5 lfu/0.5ml


Infanrix Intramuscular Suspension 25-58-10 3Age Restriction Applies (Max 18 Years)

Kinrix Intramuscular Suspension 3Age Restriction Applies (Max 18 Years)

Pediarix Intramuscular Suspension 3Age Restriction Applies (Max 18 Years)

Pentacel Intramuscular Suspension Reconstituted 3Age Restriction Applies (Max 18 Years)

Quadracel Intramuscular Suspension 3Age Restriction Applies (Max 18 Years)

TDVAX Intramuscular Suspension 2-2 LF/0.5ML 3Age Restriction Applies (Min 19 Years)

Tenivac Intramuscular Injectable 5-2 LFU 3Age Restriction Applies (Min 19 Years)

*Transthyretin Stabilizers*** - Hormones

*Transthyretin Stabilizers*** - Hormones

Vyndamax Oral Capsule 61 MG 3 PA

Vyndaqel Oral Capsule 20 MG 3 PA

*Tryptophan Hydroxylase Inhibitors*** - Drugs For The Stomach

*Tryptophan Hydroxylase Inhibitors*** - Drugs For The Stomach

Xermelo Oral Tablet 250 MG 3 PA; QL

*Ulcer Drugs* - Drugs For The Stomach

*Anticholinergic Combinations*** - Drugs For Stomach Cramps

chlordiazepoxide-clidinium oral capsule 5-2.5 mg 1

phenobarbital-belladonna alk oral elixir 16.2 mg/5ml 1

Phenohytro Oral Elixir 16.2 MG/5ML 1

Phenohytro Oral Tablet 16.2 MG 1

*Antispasmodics*** - Drugs For Stomach Cramps

dicyclomine hcl oral capsule 10 mg 1

dicyclomine hcl oral solution 10 mg/5ml 1

dicyclomine hcl oral tablet 20 mg 1

*Belladonna Alkaloids*** - Drugs For Stomach Cramps

ed-spaz oral tablet dispersible 0.125 mg 1

hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg

1

hyoscyamine sulfate oral elixir 0.125 mg/5ml 1

hyoscyamine sulfate oral solution 0.125 mg/ml 1

hyoscyamine sulfate oral tablet 0.125 mg 1

hyoscyamine sulfate oral tablet dispersible 0.125 mg 1


127


hyoscyamine sulfate sl sublingual tablet sublingual0.125 mg

1

hyoscyamine sulfate sublingual tablet sublingual 0.125 mg

1

hyosyne oral elixir 0.125 mg/5ml 1

hyosyne oral solution 0.125 mg/ml 1

NuLev Oral Tablet Dispersible 0.125 MG 1

oscimin oral tablet 0.125 mg 1

oscimin sr oral tablet extended release 12 hour 0.375 mg

1

oscimin sublingual tablet sublingual 0.125 mg 1

Symax Duotab Oral Tablet Extended Release 0.375 MG

3

Symax-SL Sublingual Tablet Sublingual 0.125 MG 1

Symax-SR Oral Tablet Extended Release 12 Hour0.375 MG

1

*H-2 Antagonists*** - Drugs For Ulcers And Stomach Acid

cimetidine hcl oral solution 300 mg/5ml 1Age Restriction Applies (Max 12 Years)

famotidine oral suspension reconstituted 40 mg/5ml 1Age Restriction Applies (Max 12 Years)

*Misc. Anti-Ulcer*** - Drugs For Ulcers And Stomach Acid

sucralfate oral suspension 1 gm/10ml 1

sucralfate oral tablet 1 gm 1

*Proton Pump Inhibitors*** - Drugs For Ulcers And Stomach Acid

AcipHex Sprinkle Oral Capsule Sprinkle 10 MG, 5 MG

3QL; Age Restriction Applies (Max 12 Years)

Dexilant Oral Capsule Delayed Release 30 MG, 60 MG

2 QL

esomeprazole magnesium oral capsule delayed release 20 mg, 40 mg

1 QL

esomeprazole magnesium oral packet 10 mg, 20 mg, 40 mg

1QL; Age Restriction Applies (Max 12 Years)

lansoprazole oral capsule delayed release 15 mg, 30 mg

1 QL

NexIUM Oral Packet 2.5 MG, 5 MG 3QL; Age Restriction Applies (Max 12 Years)

omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg

1 QL

pantoprazole sodium oral tablet delayed release 20 mg, 40 mg

1 QL

PriLOSEC Oral Packet 10 MG, 2.5 MG 3 QL

Protonix Oral Packet 40 MG 3QL; Age Restriction Applies (Max 12 Years)


128


rabeprazole sodium oral tablet delayed release 20 mg 1 QL

*Quaternary Anticholinergics*** - Drugs For Stomach Cramps

glycopyrrolate oral tablet 1 mg, 2 mg 1

methscopolamine bromide oral tablet 2.5 mg, 5 mg 1

propantheline bromide oral tablet 15 mg 1

*Ulcer Drugs - Prostaglandins*** - Drugs For Ulcers And Stomach Acid

misoprostol oral tablet 100 mcg, 200 mcg 1

*Urinary Anti-Infectives* - Drugs For The Urinary System

*Urinary Anti-Infectives*** - Drugs For Infections

methenamine hippurate oral tablet 1 gm 1

methenamine mandelate oral tablet 0.5 gm, 1 gm 1

Monurol Oral Packet 3 GM 3

nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg

1

nitrofurantoin monohyd macro oral capsule 100 mg 1

nitrofurantoin oral suspension 25 mg/5ml 1

*Urinary Antiseptic-Antispasmodic &/Or Analgesics*** - Drugs For Infections

Hyophen Oral Tablet 81.6 MG 1

me/naphos/mb/hyo1 oral tablet 81.6 mg 1

Phosphasal Oral Tablet 81.6 MG 1

Urelle Oral Tablet 81 MG 1

Uretron D/S Oral Tablet 1

Uribel Oral Capsule 118 MG 1

Urimar-T Oral Tablet 120 MG 1

urin ds oral tablet 1

uro-mp oral capsule 118 mg 1

Uryl Oral Tablet 81.6 MG 1

Ustell Oral Capsule 120 MG 1

Utira-C Oral Tablet 81.6 MG 1

Utrona-C Oral Tablet 81.6 MG 1

Vilamit MB Oral Capsule 118 MG 1

*Urinary Antispasmodics* - Drugs For The Urinary System

*Beta-3 Adrenergic Agonists*** - Drugs For The Bladder

Myrbetriq Oral Tablet Extended Release 24 Hour25 MG, 50 MG

2 QL

*Urinary Antispasmodic - Antimuscarinic (Anticholinergic)*** - Drugs For The Bladder

Gelnique Transdermal Gel 10 % 3 QL


129


oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg

1

oxybutynin chloride oral syrup 5 mg/5ml 1

oxybutynin chloride oral tablet 5 mg 1

solifenacin succinate oral tablet 10 mg, 5 mg 1 QL

tolterodine tartrate oral tablet 1 mg, 2 mg 1

Toviaz Oral Tablet Extended Release 24 Hour 4 MG, 8 MG

2 QL

trospium chloride er oral capsule extended release 24 hour 60 mg

1

trospium chloride oral tablet 20 mg 1

*Urinary Antispasmodic - Antimuscarinics (Antichol)***(New) - Drugs For The Bladder

Gelnique Transdermal Gel 10 % 3 QL

oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg

1

oxybutynin chloride oral syrup 5 mg/5ml 1

oxybutynin chloride oral tablet 5 mg 1

solifenacin succinate oral tablet 10 mg, 5 mg 1 QL

tolterodine tartrate oral tablet 1 mg, 2 mg 1

Toviaz Oral Tablet Extended Release 24 Hour 4 MG, 8 MG

2 QL

trospium chloride er oral capsule extended release 24 hour 60 mg

1

trospium chloride oral tablet 20 mg 1

*Urinary Antispasmodics - Beta-3 Adrenergic Agonists*** - Drugs For The Bladder

Myrbetriq Oral Tablet Extended Release 24 Hour25 MG, 50 MG

2 QL

*Urinary Antispasmodics - Cholinergic Agonists*** - Drugs For The Bladder

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

1

*Urinary Antispasmodics - Cholinergic Agonists*** (New) - Drugs For The Bladder

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

1

*Urinary Antispasmodics - Direct Muscle Relaxants*** - Drugs For The Bladder

flavoxate hcl oral tablet 100 mg 1

*Urinary Antispasmodics - Direct Muscle Relaxants*** (New) - Drugs For The Bladder

flavoxate hcl oral tablet 100 mg 1


130


*Vaccines* - Biological Agents

*Bacterial Vaccines*** - Vaccines

ActHIB Intramuscular Solution Reconstituted 3Age Restriction Applies (Max 18 Years)

Bexsero Intramuscular Suspension Prefilled Syringe

3

Hiberix Injection Solution Reconstituted 10 MCG 3Age Restriction Applies (Max 18 Years)

Menactra Intramuscular Injectable 3

Menveo Intramuscular Solution Reconstituted 3

Pedvax HIB Intramuscular Suspension 7.5 MCG/0.5ML


Pneumovax 23 Injection Injectable 25 MCG/0.5ML 2

Prevnar 13 Intramuscular Suspension 2

Trumenba Intramuscular Suspension Prefilled Syringe

3

*Viral Vaccine Combinations*** - Vaccines

ProQuad Subcutaneous Suspension Reconstituted


Twinrix Intramuscular Suspension Prefilled Syringe 720-20 ELU-MCG/ML


*Viral Vaccines*** - Vaccines

Afluria Quadrivalent Intramuscular Suspension 2

Afluria Quadrivalent Intramuscular Suspension Prefilled Syringe 0.5 ML

2

Engerix-B Injection Suspension 10 MCG/0.5ML, 20 MCG/ML

3

Engerix-B Intramuscular Injectable 10 MCG/0.5ML, 20 MCG/ML

3

Fluad Intramuscular Suspension Prefilled Syringe0.5 ML

2

Fluarix Quadrivalent Intramuscular Suspension Prefilled Syringe 0.5 ML

2

Flublok Quadrivalent Intramuscular Solution Prefilled Syringe 0.5 ML

2

Flulaval Quadrivalent Intramuscular Suspension 2

Flulaval Quadrivalent Intramuscular Suspension Prefilled Syringe 0.5 ML

2

Fluzone High-Dose Intramuscular Suspension Prefilled Syringe 0.5 ML

2

Fluzone Quadrivalent Intramuscular Suspension , 0.5 ML

2

Fluzone Quadrivalent Intramuscular Suspension Prefilled Syringe 0.25 ML, 0.5 ML

2

Gardasil 9 Intramuscular Suspension 2

Gardasil 9 Intramuscular Suspension Prefilled Syringe

2


131


Havrix Intramuscular Suspension 1440 EL U/ML, 720 EL U/0.5ML

3

Ipol Injection Injectable 3Age Restriction Applies (Max 18 Years)

Recombivax HB Injection Suspension 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML

3

Rotarix Oral Suspension Reconstituted 3Age Restriction Applies (Max 18 Years)

RotaTeq Oral Solution 3Age Restriction Applies (Max 18 Years)

Vaqta Intramuscular Suspension 25 UNIT/0.5ML, 50 UNIT/ML

3

Varivax Subcutaneous Injectable 1350 PFU/0.5ML 3

*Vaginal Products* - Drugs For Women

*Imidazole-Related Antifungals*** - Drugs For Infections

Gynazole-1 Vaginal Cream 2 % 3

miconazole 3 vaginal suppository 200 mg 1

terconazole vaginal cream 0.4 %, 0.8 % 1 QL

terconazole vaginal suppository 80 mg 1 QL

*Miscellaneous Vaginal Products*** - Drugs For Women

Intrarosa Vaginal Insert 6.5 MG 3 QL

*Vaginal Anti-Infectives*** - Drugs For Infections

Cleocin Vaginal Suppository 100 MG 3

clindamycin phosphate vaginal cream 2 % 1

Clindesse Vaginal Cream 2 % 3

metronidazole vaginal gel 0.75 % 1

Nuvessa Vaginal Gel 1.3 % 3

Vandazole Vaginal Gel 0.75 % 1

*Vaginal Estrogens*** - Drugs For Women

estradiol vaginal tablet 10 mcg 1

Estring Vaginal Ring 2 MG 2 QL

Femring Vaginal Ring 0.05 MG/24HR, 0.1 MG/24HR 3 QL

Imvexxy Maintenance Pack Vaginal Insert 10 MCG, 4 MCG

3

Imvexxy Starter Pack Vaginal Insert 10 MCG, 4 MCG

3

Premarin Vaginal Cream 0.625 MG/GM 2

Yuvafem Vaginal Tablet 10 MCG 1

*Vaginal Progestins*** - Drugs For Women

Crinone Vaginal Gel 4 %, 8 % 3


132


*Vasopressors* - Drugs For The Heart

*Anaphylaxis Therapy Agents*** - Drugs For Serious Allergic Reaction

epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.15 mg/0.3ml, 0.3 mg/0.3ml

1 QL

EpiPen Jr 2-Pak Injection Solution Auto-Injector0.15 MG/0.3ML

2 QL

*Vasopressors*** - Drugs For Serious Allergic Reaction

midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg 1

*Vitamins* - Drugs For Nutrition

*Vitamin D*** - Drugs For Nutrition

ergocalciferol oral capsule 1.25 mg (50000 ut) 1

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

1

*Vitamin E*** - Drugs For Nutrition

wheat germ oil oral oil 2

*Vitamin K*** - Drugs For Nutrition

phytonadione oral tablet 5 mg 1


133

Index

7T Lido ............................................ 77abacavir sulfate ................................54abacavir sulfate-lamivudine ............. 52abacavir-lamivudine-zidovudine .......52abiraterone acetate .......................... 44Absorica ..........................................69Absorica LD ....................................69Abstral .............................................16acamprosate calcium ..................... 120acarbose .......................................... 31Accu-Chek Aviva ............................96Accu-Chek Compact Plus Control ............................................ 96Accu-Chek Guide Control ............. 96Accu-Chek SmartView Control ..... 96Accutrend Glucose Control .......... 96acebutolol hcl ................................... 58acetaminophen-codeine ...................15acetaminophen-codeine #2 ..............15acetaminophen-codeine #3 ..............15acetaminophen-codeine #4 ..............15acetazolamide ..................................82acetazolamide er ..............................82acetic acid ...................................... 115acetylcysteine .................................. 67AcipHex Sprinkle ......................... 128acitretin ............................................ 72Actemra ...........................................13Actemra ACTPen ............................13ActHIB ........................................... 131Actimmune ..................................... 47Actinel Pediatric .............................67Acuvail .......................................... 113acyclovir ..................................... 55, 73Adacel ........................................... 126adapalene ........................................ 69adapalene-benzoyl peroxide ............69Adcirca ............................................62Addyi ............................................. 124adefovir dipivoxil .............................. 55Adempas .........................................62Advair Diskus ................................. 21Advair HFA ..................................... 21Advance Intuition Control ............. 96Advance Micro-Draw Control ........96Advance Micro-Draw Normal ........ 96Advocate Control Solution ............96Advocate Redi-Code+ Control ......96Adzenys ER .................................... 10Adzenys XR-ODT ........................... 10Aemcolo ..........................................41AeroChamber Mini Chamber ...... 101AeroChamber MV .........................101AeroChamber Plus Flo-Vu .......... 101AeroChamber Plus Flo-Vu Large101AeroChamber Plus Flo-Vu Medium ......................................... 101AeroChamber Plus Flo-Vu Small 101

AeroChamber Plus Flo-Vu w/Mask .......................................... 101AeroChamber Plus Flow VU ....... 101AeroChamber w/FLOWSIGnal .... 101AeroChamber Z-Stat Plus ........... 101AeroChamber Z-Stat Plus Chambr ......................................... 101AeroChamber Z-Stat Plus/Large .101AeroChamber Z-Stat Plus/Medium .................................101AeroChamber Z-Stat Plus/Small .101Aerogear Action Asthma Kit ....... 100AeroVent Plus .............................. 101Afinitor ............................................ 45Afinitor Disperz .............................. 45Afluria Quadrivalent .....................131AgaMatrix Control ..........................97Aimovig .....................................59, 63Airzone Peak Flow Meter .............100Ajovy ......................................... 59, 63Aklief ............................................... 69ak-poly-bac .................................... 112Akten ............................................. 113Akynzeo .......................................... 35Ala Scalp .........................................74ala-cort ............................................. 74Ala-Quin .......................................... 71albendazole ......................................19albuterol sulfate ................................22albuterol sulfate er ........................... 22albuterol sulfate hfa ..........................22alclometasone dipropionate ............. 74Alcoh-Glove Contoured Wipe ....... 95alcohol pads .....................................95alcohol prep ..................................... 95alcohol swabs .................................. 95Alcohol Swabstick ......................... 95alcohol wipes ................................... 95alcoh-wipe ........................................95Aldactazide ..................................... 82Alecensa ......................................... 45alendronate sodium ......................... 83alevamax ..........................................78Alevicyn Antipruritic ......................78Alevicyn Antipruritic SG ................78alfuzosin hcl er ................................. 89Alinia ............................................... 41aliskiren fumarate .............................40Alkeran ............................................47allopurinol .........................................90Allzital ............................................. 14almond oil (sweet) ............................64almotriptan malate ......................... 103Alocril ............................................112alogliptin benzoate ........................... 31alogliptin-metformin hcl .................... 31alogliptin-pioglitazone ...................... 31Alomide .........................................112Alora ................................................86

alosetron hcl .....................................88Alphagan P ................................... 114alprazolam ....................................... 20alprazolam er ................................... 20ALPRAZolam Intensol ................... 20alprazolam xr ................................... 20Alrex .............................................. 114Altabax ............................................ 70Altacaine ....................................... 113Altafrin .......................................... 111Altoprev .......................................... 37Altreno ............................................ 69Alunbrig .......................................... 45Alyq ................................................. 62Amabelz .......................................... 86amantadine hcl .................................48ambrisentan ..................................... 62amcinonide .......................................74Ameluz ............................................ 79Amicar .............................................91amiloride hcl .....................................82amiloride-hydrochlorothiazide .......... 82aminocaproic acid ............................ 91amiodarone hcl ................................ 21Amitiza ............................................ 87amitriptyline hcl ................................ 30amlodipine besy-benazepril hcl ........38amlodipine besylate ......................... 60amlodipine besylate-valsartan ......... 39amlodipine-atorvastatin ....................61amlodipine-olmesartan .....................39amlodipine-valsartan-hctz ................ 39Amnesteem .....................................70amoxapine ....................................... 30amoxicillin ...................................... 116amoxicillin-pot clavulanate ............. 117amoxicillin-pot clavulanate er .........117amphetamine sulfate ........................10amphetamine-dextroamphetamine .. 10ampicillin ........................................ 116Ampyra ..........................................122Amzeeq ........................................... 68Anacaine ......................................... 77anagrelide hcl ...................................91anastrozole ...................................... 47Androderm ......................................18AndroGel .........................................18AndroGel Pump ..............................18Angeliq ............................................86Annovera ........................................ 65Anoro Ellipta ...................................21Antara ..............................................37anucort-hc ........................................ 19Anusol-HC ...................................... 19Anzemet .......................................... 34apap-caff-dihydrocodeine ................ 15ApexiCon E .....................................74Aplenzin .......................................... 29Aplicare Alcohol Swabstick .......... 95

134

apraclonidine hcl ............................ 114aprepitant ......................................... 35Aptensio XR ....................................11Aptiom .............................................25Aptivus ............................................53Arcapta Neohaler ........................... 22Arial Chamber .............................. 101Arikayce .......................................... 11aripiprazole ...................................... 51armodafinil ....................................... 11Armour Thyroid ............................125arnica flower .....................................78Arnuity Ellipta .................................23Arymo ER ........................................16Arzol Silver Nit Applicators ...........73Ascomp-Codeine ........................... 15Asmanex (120 Metered Doses) ..... 23Asmanex (14 Metered Doses) ....... 23Asmanex (30 Metered Doses) ....... 23Asmanex (60 Metered Doses) ....... 23Asmanex (7 Metered Doses) ......... 23Asmanex HFA .................................23aspirin-dipyridamole er .....................90Assess Full Range Peak Meter ... 100Assess Low Range Peak Meter .. 100Assess Peak Flow Meter ............. 100Assure 3 Control ............................ 97Assure 4 Control Level 1 & 2 ........ 97Assure Dose Control ..................... 97Assure Dose Norm/High Control ..97Assure II Control ............................ 97Assure II Control Level 1 & 2 ........ 97Assure Prism Control Level 1 .. 97Assure Pro Control Level 1 & 2 .... 97Astagraf XL .....................................57Astero ..............................................77Asthma Check Meter-Zone System .......................................... 100AsthmaMentOr ............................. 100AsthmaPack I ............................... 100AsthmaPack II .............................. 100AsthmaPack III ............................. 101Atabex EC ..................................... 106Atabex OB .....................................106atazanavir sulfate .............................53atenolol ............................................ 58atenolol-chlorthalidone .....................40atomoxetine hcl ................................10atopaderm ........................................78Atopiclair ........................................ 78atorvastatin calcium ......................... 37atovaquone ...................................... 41atovaquone-proguanil hcl .................41Atripla ..............................................52atropine sulfate .............................. 111Atrovent HFA ..................................23Aubagio .........................................121Augmentin .................................... 117Auryxia ............................................88Austedo .........................................121

Avandia ........................................... 33Avar Cleanser .................................69Avar-e Emollient .............................69Avar-e Green .................................. 69Aveeno Active Nat Pure Renewal .79Avenova .......................................... 76avidoxy ...........................................125Avita ................................................ 70Avonex Pen .................................. 121Avonex Prefilled ...........................121Ayvakit ............................................ 45Azasan ............................................ 57AzaSite .......................................... 112azathioprine ..................................... 57azelaic acid ...................................... 79azelastine hcl ......................... 110, 112azelastine-fluticasone .................... 110Azelex ..............................................70azithromycin .....................................95Azopt ............................................. 113Azurette ...........................................64bacitracin ........................................112bacitracin-polymyxin b ................... 112bacitra-neomycin-polymyxin-hc ..... 114baclofen ......................................... 109Bal-Care DHA ............................... 106Balcoltra ..........................................64balsalazide disodium ........................88balsam peru-castor oil ......................81Balversa .......................................... 43Banzel ............................................. 25Baqsimi One Pack ..........................31Baqsimi Two Pack ......................... 31Baraclude ........................................55base g almond oil (sweet) ................ 64base x ............................................ 118Baxdela ........................................... 87BD Swabs Single Use Butterfly .... 95beau rx ............................................. 79Beconase AQ ................................110Bekyree ........................................... 64Belsomra .......................................115benazepril hcl ...................................38benazepril-hydrochlorothiazide ........ 38Benlysta .......................................... 56bensal hp ......................................... 77benzaldehyde .................................117benzalkonium chloride ..................... 52benzepro .......................................... 70BenzePrO ........................................70BenzePrO Creamy Wash ............... 70BenzePrO Foaming Cloths ............70BenzePrO Short Contact ............... 70benznidazole ....................................19benzoin ............................................ 80benzonatate ..................................... 66benzoyl perox-hydrocortisone ..........69benzoyl peroxide ..............................70benzoyl peroxide-erythromycin ........ 69benztropine mesylate .......................48

benzyl alcohol ................................ 117benzyl benzoate ...............................64Bepreve .........................................112Besivance ..................................... 112Betadine Ophthalmic Prep .......... 113betamethasone dipropionate ........... 74betamethasone dipropionate aug .... 74betamethasone valerate .................. 74betaxolol hcl ............................. 58, 111bethanechol chloride ......................130Bethkis ............................................ 11Betimol ..........................................111Betoptic-S ..................................... 111Bevespi Aerosphere ...................... 21bexarotene ....................................... 48Bexsero .........................................131bicalutamide .....................................44BiDil .................................................61Biktarvy ...........................................52bimatoprost .................................... 115Binosto ............................................83bio-statin .......................................... 35bisoprolol fumarate .......................... 58bisoprolol-hydrochlorothiazide ......... 40Blephamide ...................................114Blephamide S.O.P. ....................... 114Boostrix ........................................ 126boric acid ..........................................78bosentan .......................................... 62Bosulif .............................................45bp 10-1 .............................................69bp cleansing wash ........................... 69bp wash ............................................70bpco ................................................. 81bpo ................................................... 70bpo foaming cloths ...........................70Braftovi ........................................... 44breathe ease large ......................... 101breathe ease medium .................... 101breathe ease small .........................101BreatheRite ...................................101BreatheRite Coll Spacer Adult ....101BreatheRite Coll Spacer Child .... 101BreatheRite Coll Spacer Infant ... 101BreatheRite Rigid Spacer/Mask ..101BreatheRite Spacer Neonate .......101BreatheRite Spacer Small Child . 101BreatheRite/Large Mask .............. 101BreatheRite/Medium Mask .......... 101BreatheRite/Small Mask .............. 102Breo Ellipta ..................................... 21Brilinta .......................................82, 90brimonidine tartrate ........................ 114Briviact ............................................25Bromfed DM ....................................67bromfenac sodium (once-daily) ......113bromocriptine mesylate ....................48BromSite ....................................... 113Brovana ...........................................22Brukinsa ..........................................45

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Bryhali .............................................74budesonide ................................ 23, 65budesonide er .................................. 65bumetanide ...................................... 82Bunavail .......................................... 18Bupap ..............................................14Buphenyl .........................................85buprenorphine ..................................18buprenorphine hcl ............................ 18buprenorphine hcl-naloxone hcl .......18bupropion hcl ................................... 29bupropion hcl er (smoking det) ...... 123bupropion hcl er (sr) .........................29bupropion hcl er (xl) ......................... 29buspirone hcl ....................................20butalbital-acetaminophen .................14butalbital-apap-caff-cod ................... 15butalbital-apap-caffeine ....................14butalbital-asa-caff-codeine ...............15butalbital-aspirin-caffeine ................. 14butorphanol tartrate ..........................18Butrans ........................................... 18Bystolic ........................................... 58cabergoline ...................................... 83Cablivi ............................................. 56Cabometyx ......................................45caffeine citrate ..................................10calcipotriene ...............................72, 73calcipotriene-betameth diprop ..........80calcitonin (salmon) ........................... 83Calcitrene ........................................73calcitriol ...................................... 73, 84calcium acetate (phos binder) ..........89calcium folinate ................................ 63calcium-folic acid plus d ................. 104Calquence .......................................45Cambia .......................................... 103candesartan cilexetil ........................ 39candesartan cilexetil-hctz .................39capecitabine .....................................44Capex .............................................. 74Caprelsa ..........................................45captopril ........................................... 38captopril-hydrochlorothiazide ........... 38Carbaglu ......................................... 84carbamazepine ................................ 25carbamazepine er ............................ 25Carbatrol ......................................... 25carbidopa ......................................... 49carbidopa-levodopa ......................... 49carbidopa-levodopa er ..................... 49carbidopa-levodopa-entacapone ..... 49carbinoxamine maleate ....................36Cardizem LA ................................... 60Cardura XL ......................................89CareSens Control A ....................... 97CareTouch Alcohol Prep ............... 95carisoprodol ................................... 109carisoprodol-aspirin ........................110carisoprodol-aspirin-codeine ..........110

CaroSpir ..........................................82carteolol hcl ....................................111Cartia XT ......................................... 60carvedilol ..........................................58carvedilol phosphate er ....................58cascara sagrada .............................. 94castor oil ...........................................64Caverject .........................................61Caverject Impulse .......................... 61Cayston .........................................105cefaclor ............................................ 63cefaclor er ........................................ 63cefadroxil ..........................................62cefdinir ............................................. 63cefditoren pivoxil .............................. 63cefixime ............................................63cefpodoxime proxetil ........................ 63cefprozil ............................................63cefuroxime axetil .............................. 63Celacyn ........................................... 79celecoxib .......................................... 13Celontin ...........................................28Centany ...........................................71cephalexin ........................................62Cerdelga ..........................................91Cervidil ..........................................116Cetacaine ........................................ 80cetirizine hcl ..................................... 36cevimeline hcl ................................ 105Chantix ..........................................123Chantix Continuing Month Pak ...123Chantix Starting Month Pak ........ 123Chemet ............................................34Chemstrip K ....................................81Chemstrip uGK ...............................81cheratussin ac ..................................66chlordiazepoxide hcl ........................ 20chlordiazepoxide-amitriptyline ........120chlordiazepoxide-clidinium .............127chlorhexidine gluconate ........... 52, 105chloroquine phosphate .....................41chlorothiazide ...................................82chlorpromazine hcl ...........................51chlorthalidone ...................................82chlorzoxazone ................................109Cholbam ..........................................59cholestyramine .................................36cholestyramine light ......................... 36choline-mag trisalicylate ...................15Ciclodan ..........................................71ciclopirox .......................................... 71ciclopirox olamine ............................ 71cilostazol .......................................... 90Ciloxan .......................................... 112Cimduo ............................................52cimetidine hcl ................................. 128cinacalcet hcl ................................... 83Cipro ................................................87Cipro HC ....................................... 115Ciprodex ....................................... 115

ciprofloxacin hcl ............... 87, 112, 115citalopram hydrobromide ................. 29CitraNatal 90 DHA ........................ 108CitraNatal Assure .........................108CitraNatal Bloom ..........................106CitraNatal Bloom DHA ................. 108CitraNatal DHA ............................. 108CitraNatal Harmony ..................... 108CitraNatal Rx ................................ 106Claravis ........................................... 70clarithromycin ...................................95clarithromycin er ...............................95clemastine fumarate .........................36Clenpiq ............................................93Cleocin .......................................... 132Clever Choice Glucose Control .... 97Clever Choice Holding Chamber 102Climara Pro .....................................86Clindacin ETZ ................................. 68Clindacin-P ..................................... 68clindamycin hcl .................................41clindamycin palmitate hcl ................. 41clindamycin phos-benzoyl perox ......69clindamycin phosphate ............ 68, 132clindamycin-tretinoin ........................ 69Clindesse ...................................... 132CLn Healthy Scalp ......................... 79CLn Moisture Rich Gentle ............. 79clobazam ..........................................25clobetasol prop emollient base ........ 74clobetasol propionate .......................74clobetasol propionate e ....................74clobetasol propionate emulsion ....... 74clocortolone pivalate ........................ 74Clodan .............................................74clomipramine hcl .............................. 30clonazepam ......................................25clonidine ...........................................40clonidine hcl ..................................... 40clonidine hcl er ................................. 10clopidogrel bisulfate ......................... 91clorazepate dipotassium .................. 20clotrimazole ....................................105clotrimazole-betamethasone ............71clozapine ..........................................50c-nate dha ...................................... 106Coartem .......................................... 41Coca Cola ....................................... 35cocoa butter ................................... 118coconut oil ........................................64codeine sulfate .................................16colchicine ......................................... 90colchicine-probenecid ...................... 90colesevelam hcl ............................... 36colestipol hcl .............................. 36, 37Colocort .......................................... 19Combigan ..................................... 111CombiPatch .................................... 86Combivent Respimat ..................... 21Combivir ......................................... 52

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Cometriq (100 mg Daily Dose) ...... 45Cometriq (140 mg Daily Dose) ...... 45Cometriq (60 mg Daily Dose) ........ 45Compact Space Chamber ........... 102Compact Space Chamber/Lg Mask .............................................. 102Compact Space Chamber/Med Mask .............................................. 102Compact Space Chamber/Sm Mask .............................................. 102Complera ........................................ 52complete natal dha .........................108completenate ................................. 106Compro ........................................... 51Co-Natal FA .................................. 106Concept DHA ................................106Concept OB .................................. 106Condylox .........................................77constulose ........................................94Contour Next Control .................... 97control .............................................. 97Cool Control A ................................97Cool Control B ................................97CopaSil ............................................79Copaxone ......................................122Copiktra ........................................ 118Cordran ........................................... 74Corlanor ........................................ 124Cortane-B ........................................80cortisone acetate ..............................65Cortisporin ......................................70Cosentyx .........................................72Cosentyx (300 MG Dose) ...............72Cosentyx Sensoready (300 MG) ... 72Cosentyx Sensoready Pen ............72Cotellic ............................................ 45cottonseed oil ...................................64Coumadin ....................................... 24Covaryx ...........................................86Covaryx HS .....................................86Creon ...............................................81Cresemba ........................................35Crinone ......................................... 132Crixivan ...........................................53cromolyn sodium ................22, 87, 112Crotan ............................................. 79Curity Alcohol Preps ..................... 95Curity Alcohol Swabs .................... 95cvs alcohol prep pads ...................... 95cvs creamy acne face wash .............70cvs distilled water ...........................117cvs isopropyl alcohol wipes ..............80CVS Ketone Care ........................... 81cvs mineral oil .................................. 94cvs prep ........................................... 95cvs purified water ........................... 117cyanocobalamin ............................... 91cyclobenzaprine hcl ....................... 109cyclobenzaprine hcl er ................... 109Cyclomydril .................................. 111

cyclopentolate hcl .......................... 111cyclophosphamide ........................... 47cycloserine ....................................... 42Cycloset .......................................... 31cyclosporine ..................................... 56cyclosporine modified ...................... 56cyproheptadine hcl ...........................36Cystadane .......................................84Cystagon .........................................89Cystaran ........................................115Cytomel .........................................126cytra k crystals ................................. 89cytra-2 .............................................. 89cytra-k .............................................. 89dalfampridine er ............................. 122Daliresp ...........................................23danazol ............................................ 18dantrolene sodium ......................... 110dapsone ..................................... 41, 68Daptacel ........................................ 126Dara ................................................. 79Daraprim ......................................... 41Daurismo ........................................ 44Daytrana ..........................................11DDAVP Rhinal Tube .......................85Debacterol .................................... 105Decadron ........................................ 65deferasirox ....................................... 34Delstrigo ......................................... 52demeclocycline hcl .........................125Demser ............................................39Denavir ............................................73Depakote .........................................28Depakote ER ...................................28Depakote Sprinkles ........................28Dermazene ......................................71Dermulcera ..................................... 81Descovy .......................................... 52desipramine hcl ................................30desmopressin ace spray refrig .........85desmopressin acetate ......................85desmopressin acetate spray ............ 85desogestrel-ethinyl estradiol ............ 64Desonate .........................................74desonide .......................................... 74desoximetasone ...............................75desvenlafaxine er .............................30desvenlafaxine succinate er .............30dexamethasone ............................... 65Dexamethasone Intensol ...............65dexamethasone sodium phosphate....................................................... 114dexchlorpheniramine maleate ..........36Dexcom G4 Plat Ped Rcv/Share ... 97Dexcom G4 Plat Ped Receiver ...... 97Dexcom G4 Platinum Rcv/Share .. 97Dexcom G4 Platinum Receiver ..... 97Dexcom G4 Platinum Transmitter 97Dexcom G4 Sensor ........................ 97Dexcom G5 Mob/G4 Plat Sensor .. 97

Dexcom G5 Mobile Receiver .........97Dexcom G5 Mobile Transmitter .... 97Dexcom G6 Receiver ..................... 97Dexcom G6 Sensor ........................ 97Dexcom G6 Transmitter ................ 97Dexeryl ............................................ 78Dexilant ......................................... 128dexmethylphenidate hcl ................... 11dexmethylphenidate hcl er ............... 11dextroamphetamine sulfate ..............10dextroamphetamine sulfate er ......... 10DHS ................................................. 79DHS Color Safe .............................. 79DHS Conditioning Rinse ............... 79Diacomit ..........................................25DiaScreen 10 .................................. 97DiaScreen 1B ..................................97DiaScreen 1G ..................................97DiaScreen 1K ..................................97DiaScreen 2GK ............................... 97DiaScreen 2GP ............................... 97DiaScreen 3 .................................... 97DiaScreen 4NL ................................97DiaScreen 4ObL ............................. 97DiaScreen 4pH ................................97DiaScreen 5 .................................... 97DiaScreen 6 .................................... 98DiaScreen 7 .................................... 98DiaScreen 8 .................................... 98DiaScreen 9 .................................... 98diascreen liquid urine control ........... 98Diastat AcuDial ...............................25Diastat Pediatric .............................25diathrive glucose control soln ...........98diatrue control level 1 .......................98diatrue control level 2 .......................98diatrue control level 3 .......................98diazepam ................................... 20, 25Diazepam Intensol ......................... 20diazoxide ..........................................31diclofenac epolamine ....................... 71diclofenac potassium ....................... 13diclofenac sodium ........ 13, 71, 72, 113diclofenac sodium er ........................ 13diclofenac-misoprostol ..................... 13dicloxacillin sodium ........................ 117dicyclomine hcl ...............................127didanosine ........................................54Dificid .............................................. 95diflorasone diacetate ........................75diflunisal ........................................... 15Digitek ............................................. 61Digox ............................................... 61digoxin ..............................................61dihydroergotamine mesylate ..........103Dilantin ............................................28Dilantin Infatabs ............................. 28Dilatrate-SR .................................... 19diltiazem hcl ..................................... 60diltiazem hcl er ................................. 60

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diltiazem hcl er beads ...................... 60diltiazem hcl er coated beads .......... 60dilt-xr ................................................ 60Dipentum ........................................ 88diphenoxylate-atropine .....................34diphtheria-tetanus toxoids dt ..........127dipyridamole .....................................91disopyramide phosphate ..................20distillata distilled water ................... 117distilled water ................................. 117disulfiram ........................................120Diuril ................................................82divalproex sodium ............................ 28divalproex sodium er ........................28Divigel ............................................. 86dofetilide ...........................................21donepezil hcl .................................. 120Doptelet ...........................................91Doryx .............................................125dorzolamide hcl ..............................113dorzolamide hcl-timolol mal ........... 111Dovato .............................................52doxazosin mesylate ......................... 40doxepin hcl .................................30, 72doxercalciferol ..................................84doxycycline ...................................... 79doxycycline hyclate ........................ 125doxycycline monohydrate .............. 125Dritho-Creme HP ............................ 73dronabinol ........................................ 35drospiren-eth estrad-levomefol ........ 64Droxia ..............................................91Drysol ..............................................78Duavee ............................................ 87Duet DHA 400 ............................... 106Duet DHA Balanced ..................... 106duloxetine hcl ................................... 30Duobrii ............................................ 80Duo-Care Control Solution ............98Dupixent ..........................................58duraxin ............................................. 14Durezol ..........................................114dutasteride ....................................... 89dutasteride-tamsulosin hcl ............... 90Dutoprol .......................................... 40Dvorah .............................................15Dyanavel XR ................................... 10E.E.S. 400 ........................................95EasiVent ........................................102EasiVent Mask Large ................... 102EasiVent Mask Medium ............... 102EasiVent Mask Small ................... 102easy plus ii control ........................... 98Easy Step Control .......................... 98easy talk control ............................... 98Easy Touch Alcohol Prep Medium ........................................... 95Easy Touch Control High & Low .. 98easy trak control ...............................98EasyGluco Control .........................98

EasyGluco Plus Level 1 .................98EasyMax 15 Level 1 Control ..........98EasyMax 15 Level 1-2 Control ...... 98EasyMax 15 Level 2 Control ..........98EasyMax Control ............................98EasyMax Control Normal/Low ...... 98econazole nitrate ..............................76Ecoza ...............................................76Edarbi ..............................................39Edarbyclor ...................................... 39Edex ................................................ 61Edluar ..............................................92ed-spaz .......................................... 127Edurant ........................................... 54EEMT ............................................... 86EEMT HS ......................................... 86efavirenz .......................................... 54Effer-K ........................................... 104element compact control 2 ...............98element compact control 3 ...............98Element Control ............................. 98Elestrin ............................................86Eletone ............................................ 78eletriptan hydrobromide ................. 103Eliquis ............................................. 24Eliquis DVT/PE Starter Pack ......... 24Elite-OB .........................................106Elixophyllin .....................................24Ella ...................................................65Elmiron ............................................89Embrace Control ............................ 98Embrace Evo Control Level 1 ....... 98Embrace Evo Control Level 2 ....... 98Embrace Glucose Control .............98Embrace Pro Glucose Control ......98Embrace Talk Glucose Control .....98Emcyt .............................................. 47Emend ............................................. 35Emgality .................................... 60, 63Emgality (300 MG Dose) .......... 60, 63Emsam ............................................ 29Emtriva ............................................54Emverm ...........................................19enalapril maleate ..............................38enalapril-hydrochlorothiazide ........... 38EnBrace HR .................................. 106Enbrel ..............................................14Enbrel Mini ......................................14Enbrel SureClick ............................ 14Endocet ...........................................17Engerix-B ...................................... 131enoxaparin sodium ...........................24Enstilar ............................................81entacapone ...................................... 49entecavir .......................................... 55Entereg ............................................88Entresto ........................................ 110enulose ............................................ 88Envarsus XR ...................................57Epaned ............................................ 38

Epclusa ........................................... 92Epidiolex ......................................... 25Epiduo Forte ...................................69Epifoam ...........................................80epinastine hcl ................................. 112epinephrine .................................... 133EpiPen Jr 2-Pak ............................133Epitol ............................................... 25Epivir ............................................... 54Epivir HBV ...................................... 55eplerenone ....................................... 40Epzicom .......................................... 52eq mineral oil ....................................94eql alcohol swabs .............................96Equetro ........................................... 49ergocalciferol ..................................133ergoloid mesylates ......................... 122Ergomar ........................................ 103ergotamine-caffeine ....................... 103Erivedge ..........................................44Erleada ............................................ 44erlotinib hcl .......................................46Ertaczo ............................................ 76ery .................................................... 68Ery-Tab ............................................95Erythrocin Stearate ........................95erythromycin ...................... 68, 69, 112erythromycin base ............................95erythromycin ethylsuccinate .............95Esbriet ...........................................123escitalopram oxalate ........................ 29Esgic ............................................... 15esomeprazole magnesium .............128essentra wipes 9x9" .........................80est estrogens-methyltest ..................86est estrogens-methyltest ds ............. 86est estrogens-methyltest hs ............. 86estazolam .........................................92estradiol ................................... 86, 132estradiol-norethindrone acet ............ 86Estring ...........................................132Estrogel ...........................................86eszopiclone ...................................... 92ethacrynic acid ................................. 82ethambutol hcl ..................................42ethosuximide ....................................28ethyl chloride ............................80, 126etodolac ........................................... 13etodolac er ....................................... 13etoposide ......................................... 47Eucrisa .......................................... 119Euthyrox ....................................... 126Evamist ........................................... 86EvenCare Control Low/High ......... 98EvenCare G2 Low/High Control ....98EvenCare G3 Low/High Control ....98EvenCare Mini Control .................. 98everolimus ........................................45Evolution Control ...........................98Evotaz ............................................. 52

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Exelderm .........................................76exemestane ..................................... 47Exjade ............................................. 34Exoderm ..........................................71Extavia .......................................... 121ezetimibe ..........................................37ezetimibe-simvastatin ...................... 37Fabior .............................................. 70FaLessa ...........................................64famciclovir ........................................ 55famotidine ...................................... 128Fanapt ............................................. 50Fanapt Titration Pack .................... 50Farxiga ............................................ 33Farydak ........................................... 45Fasenra Pen ....................................93Fattyblend .....................................118febuxostat ........................................ 90felbamate ......................................... 27Felbatol ........................................... 27felodipine er ..................................... 60Femring .........................................132fenofibrate ........................................ 37fenofibrate micronized ......................37fenofibric acid ...................................37fenoprofen calcium ...........................13Fenortho ......................................... 13fentanyl ............................................ 16fentanyl citrate ..................................16Fentora ............................................16Ferriprox ......................................... 34Fetzima ............................................30Fetzima Titration ............................ 30Fiasp ................................................32Fiasp FlexTouch .............................32Fiasp PenFill ...................................32Fifty50 Alcohol Prep ...................... 96Finacea ............................................79finasteride ........................................ 89Firdapse .......................................... 42Firvanq ............................................ 90Flac ................................................115Flarex ............................................ 114Flavor Blend ................................. 117flavor plus .......................................117flavor sweet ....................................117flavor sweet-sf ................................117flavoxate hcl ................................... 130flecainide acetate ............................. 21Flector ............................................. 71Flexichamber ................................102Flexichamber Adult Mask/Small . 102Flexichamber Child Mask/Large . 102Flexichamber Child Mask/Small . 102flolipid ...............................................37Floriva ........................................... 104Flovent Diskus ............................... 23Flovent HFA ....................................23Fluad ............................................. 131Fluarix Quadrivalent .................... 131

Flublok Quadrivalent ................... 131fluconazole .......................................35flucytosine ........................................ 35fludrocortisone acetate .....................66Flulaval Quadrivalent ...................131flunisolide ....................................... 110fluocinolone acetonide ............. 75, 115fluocinolone acetonide body ............ 75fluocinolone acetonide scalp ............75fluocinonide ......................................75fluocinonide emulsified base ............75Fluorabon ..................................... 104fluorometholone ............................. 114Fluoroplex .......................................72fluorouracil ....................................... 72fluoxetine hcl .................................... 29fluoxetine hcl (pmdd) ......................122fluphenazine hcl ............................... 51flurandrenolide ................................. 75flurazepam hcl ..................................92flurbiprofen ....................................... 13flurbiprofen sodium ........................ 113flutamide .......................................... 44fluticasone propionate ..............75, 110fluvastatin sodium ............................ 37fluvastatin sodium er ........................ 37fluvoxamine maleate ........................ 30fluvoxamine maleate er ....................29Fluzone High-Dose ...................... 131Fluzone Quadrivalent .................. 131FML ................................................114FML Forte ......................................114folic acid ........................................... 91Folivane-OB ..................................106fondaparinux sodium ........................24FORA Control ................................. 98ForaCare GDH Control .................. 99formaldehyde ................................... 52FortisCare Control ......................... 99Fosamax Plus D ............................. 83fosamprenavir calcium ..................... 53fosinopril sodium .............................. 38fosinopril sodium-hctz ...................... 38Fosrenol ..........................................89Free & Clear ....................................80FreeStyle Control Solution ............99FreeStyle Libre 14 Day Reader ..... 99FreeStyle Libre 14 Day Sensor ..... 99FreeStyle Libre Reader ..................99FreeStyle Libre Sensor System .... 99frovatriptan succinate .....................103furosemide ....................................... 82Fuzeon ............................................ 53Fycompa ......................................... 24g tussin ac ........................................66gabapentin ....................................... 25Gabitril ............................................ 27Galafold ...........................................83galantamine hydrobromide ............ 121galantamine hydrobromide er ........ 121

Galzin ............................................ 105Gardasil 9 ......................................131gatifloxacin ..................................... 112Gattex ..............................................88GaviLyte-C ...................................... 94GaviLyte-H ...................................... 94GaviLyte-N with Flavor Pack .........94ge100 control ................................... 99Gebauers Pain Ease .............. 80, 126Gebauers Spray and Stretch .80, 126Gelclair ..........................................105Gelfilm ...........................................115Gelnique ................................129, 130gemfibrozil ........................................37generlac ........................................... 88Gengraf ........................................... 56Genotropin ......................................84Genotropin MiniQuick ................... 84Gentak ...........................................112gentamicin sulfate .................... 71, 112Genvoya ..........................................52geri-shampoo/shea butter ................ 80Gilenya .......................................... 123Gilotrif ............................................. 46glatiramer acetate .......................... 122Glatopa ..........................................122Gleevec ........................................... 46Gleostine .........................................48glimepiride ........................................33glipizide ............................................ 33glipizide er ........................................33glipizide xl ........................................ 33glipizide-metformin hcl ..................... 33global alcohol prep ease .................. 96Gloperba ......................................... 90GlucaGen HypoKit ......................... 31Glucagon Emergency .................... 31Glucocard 01 Control .................... 99Glucocard Expression Control ..... 99Glucocard Shine Control ...............99Glucocard X-Sensor Control .........99GlucoCom Control ......................... 99glucose control .................................99glutaraldehyde ................................. 52glyburide .......................................... 33glyburide micronized ........................ 33glyburide-metformin ......................... 33glycerin .............................................76glycolic acid ......................................73glycopyrrolate .................................129Glyxambi .......................................124gnp alcohol swabs ........................... 96GNP Easy Touch Cont High/Low ..99gnp glycerin ......................................76Golytely ...........................................94GoNitro ............................................19goodsense mineral oil ...................... 94granisetron hcl ................................. 35grape syrup .................................... 117Grastek ............................................59

139

griseofulvin microsize .......................35griseofulvin ultramicrosize ................35guaiatussin ac .................................. 66guaifenesin ac ..................................66guaifenesin dac ................................67guaifenesin-codeine .........................67guanfacine hcl ..................................40guanfacine hcl er ..............................10guanidine hcl ....................................42Gynazole-1 ....................................132halcinonide .......................................75halobetasol propionate .....................75Halog ............................................... 75haloperidol ....................................... 50haloperidol lactate ............................50Harvoni ............................................92Havrix ............................................ 132h-e-b incontrol alcohol ......................96Hemangeol ......................................58Hemmorex-HC ................................ 19Hepsera ...........................................55Hetlioz ............................................. 93Hiberix ...........................................131Histex-AC ........................................68hm castor oil .....................................64hm glycerin .......................................76hm mineral oil ...................................94hm sterile alcohol prep .....................96Homatropaire ................................111HPR ................................................. 78HPR Plus .........................................78HPR PLUS HydroGel ......................78Humatrope ...................................... 84Humira .............................................12Humira Pediatric Crohns Start ......12Humira Pen ..................................... 12Humira Pen-CD/UC/HS Starter ......12Humira Pen-Ps/UV/Adol HS Start . 12HumuLIN R U-500 (CONCENTRATED) ........................ 32HumuLIN R U-500 KwikPen ...........32Hycamtin .........................................48Hyclodex ......................................... 80hydralazine hcl ................................. 40hydrochlorothiazide ..........................82hydrocod polst-cpm polst er .............67hydrocodone-acetaminophen .......... 15hydrocodone-homatropine ............... 66hydrocodone-ibuprofen .................... 15hydrocortisone ..................... 19, 65, 75hydrocortisone acetate .....................19hydrocortisone butyr lipo base ......... 75hydrocortisone butyrate ................... 75hydrocortisone valerate ....................75hydrocortisone-acetic acid ............. 115hydrocortisone-iodoquinol ................71hydromet .......................................... 66hydromorphone hcl .......................... 16hydromorphone hcl er ...................... 16hydroxychloroquine sulfate .............. 41

hydroxyprogesterone caproate 48, 120hydroxyurea ..................................... 47hydroxyzine hcl ................................ 20hydroxyzine pamoate .......................20Hylatopic Plus ................................ 78Hyophen ........................................129hyoscyamine sulfate .............. 127, 128hyoscyamine sulfate er .................. 127hyoscyamine sulfate sl ...................128hyosyne ..........................................128HyperSal ......................................... 67Hysingla ER .................................... 16ibandronate sodium ......................... 83Ibrance ............................................ 68IBU ...................................................13ibuprofen .......................................... 13Iclusig ..............................................46IDHIFA ............................................. 93Ilevro ............................................. 113imatinib mesylate ............................. 46Imbruvica ........................................ 46imipramine hcl ..................................30imipramine pamoate ........................ 30imiquimod .........................................77Impavido ......................................... 41Imvexxy Maintenance Pack .........132Imvexxy Starter Pack ...................132In Touch Glucose Control ............. 99Inbrija .............................................. 48Increlex ........................................... 85Incruse Ellipta ................................ 23indapamide ...................................... 82Inderal XL ........................................58Indocin ............................................ 13indomethacin ....................................13indomethacin er ............................... 13Infanrix .......................................... 127Infinity Control ............................... 99Infinity Voice ...................................99Ingrezza .........................................121Inlyta ................................................46Inrebic ............................................. 47InspiraChamber/Large .................102InspiraChamber/Medium ............. 102InspiraChamber/Mouthpiece .......102InspiraChamber/Small ................. 102Inspirease ..................................... 102Intelence ......................................... 54Intrarosa ........................................132Inveltys ..........................................114Invirase ........................................... 53iodine strong .................................. 104iodine tincture ...................................52iodoquimez-hc ..................................71iodoquinol-hydrocortisone-aloe ........71Iopidine ......................................... 114Ipol .................................................132ipratropium bromide ................. 23, 110ipratropium-albuterol ........................ 21irbesartan ......................................... 39

irbesartan-hydrochlorothiazide .........39Iressa ...............................................46Isentress ......................................... 53Isentress HD ................................... 53isoniazid ........................................... 42isopropyl alcohol .............................. 80isopropyl alcohol wipes .................... 80Isopto Atropine ............................ 111isosorbide dinitrate ...........................19isosorbide mononitrate .....................19isosorbide mononitrate er ................ 19isotretinoin ........................................70isoxsuprine hcl ................................. 61isradipine ..........................................60Isturisa ............................................ 66itraconazole ......................................35ivermectin .........................................19Jadenu ............................................ 34Jadenu Sprinkle ............................. 34Jakafi ...............................................47Jantoven ......................................... 24Janumet .......................................... 31Janumet XR .................................... 31Januvia ............................................31Jardiance ........................................ 33Jatenzo ............................................18Jinteli ...............................................86Jublia ...............................................76Juluca ..............................................52Juxtapid .......................................... 37Jynarque ......................................... 85Kadian ............................................. 16Kaitlib Fe .........................................64Kaletra .............................................52Kalydeco ....................................... 123Karbinal ER .....................................36Kariva .............................................. 64Katerzia ........................................... 60KelaRx .............................................79Keppra .............................................25Keppra XR .......................................26Kerr Triple Dye Swabs ...................52Kerydin ..........................................116ketoconazole ..............................35, 77Keto-Diastix .................................... 81ketone test ....................................... 81ketoprofen er ....................................13ketorolac tromethamine ........... 13, 113Ketostix ...........................................81Keveyis ........................................... 82Kinrix .............................................127Kionex ..................................... 57, 119Kisqali (200 MG Dose) ................... 68Kisqali (400 MG Dose) ................... 68Kisqali (600 MG Dose) ................... 68Kisqali Femara (400 MG Dose) ..... 47Kisqali Femara (600 MG Dose) ..... 47Kisqali Femara(200 MG Dose) ...... 47Kitabis Pak ......................................11Klor-Con ........................................104

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Klor-Con 10 ...................................104Klor-Con M10 ................................104Klor-Con M15 ................................104Klor-Con M20 ................................104Klor-Con Sprinkle ........................ 104Klor-Con/EF .................................. 104Korlym .............................................33Koselugo .........................................45kp folic acid ...................................... 91K-Phos .......................................... 104K-Phos No 2 ....................................89K-Prime ......................................... 104Kristalose ........................................94Kuvan .............................................. 85labetalol hcl ...................................... 58Lacrisert ........................................111lactic acid e ...................................... 76lactulose ...........................................94lactulose encephalopathy ................ 88LaMICtal .......................................... 26LaMICtal ODT ................................. 26LaMICtal Starter ............................. 26LaMICtal XR .................................... 26lamivudine ..................................54, 55lamivudine-zidovudine ..................... 52lamotrigine ....................................... 26lamotrigine er ................................... 26lamotrigine starter kit-blue ................26lamotrigine starter kit-green ............. 26lamotrigine starter kit-orange ........... 26Lanoxin ........................................... 61lansoprazole ...................................128Lantus ............................................. 32Lantus SoloStar ............................. 32Lastacaft ....................................... 112latanoprost ..................................... 115Latuda ............................................. 50Layolis FE ....................................... 65Lazanda ...........................................16LDO Plus .........................................77Leena ...............................................65leflunomide .......................................14Lenvima (10 MG Daily Dose) .........46Lenvima (12 MG Daily Dose) .........46Lenvima (14 MG Daily Dose) .........46Lenvima (18 MG Daily Dose) .........46Lenvima (20 MG Daily Dose) .........46Lenvima (24 MG Daily Dose) .........46Lenvima (4 MG Daily Dose) ...........46Lenvima (8 MG Daily Dose) ...........46Letairis ............................................ 62letrozole ........................................... 47leucovorin calcium ..................... 47, 63Leukeran ......................................... 47leuprolide acetate .............................47levalbuterol hcl ................................. 22levalbuterol tartrate .......................... 22levetiracetam ....................................26levetiracetam er ............................... 26Levicyn ............................................78

Levitra ............................................. 62levobunolol hcl ............................... 111levocarnitine .....................................83levofloxacin .............................. 87, 112levorphanol tartrate .......................... 16Levo-T ........................................... 126levothyroxine sodium ..................... 126Levoxyl ..........................................126Levulan Kerastick .......................... 79Lexiva ..............................................53Liberty Glucose Control ................ 99Liberty Glucose Control Mid .........99lidocaine ...........................................77lidocaine hcl ............................. 77, 105lidocaine hcl urethral/mucosal ..........77lidocaine-prilocaine .......................... 80lindane ............................................. 79linezolid ............................................ 41linseed oil ......................................... 64Linzess ............................................88liothyronine sodium ........................ 126lisinopril ............................................ 38lisinopril-hydrochlorothiazide ............38LiteAire ..........................................102lithium ...............................................49lithium carbonate ..............................49lithium carbonate er ......................... 49Lithobid ...........................................49Lithostat ..........................................90Livalo ...............................................37Lo Loestrin Fe ................................ 64Lokelma .................................. 57, 120Lonsurf ............................................47lopinavir-ritonavir ..............................53Lopreeza ......................................... 86lorazepam ........................................ 20LORazepam Intensol ..................... 20Lorbrena ......................................... 46Lorcet .............................................. 16Lorcet HD ........................................15Lorcet Plus ..................................... 16Lortab ..............................................16Lorzone ......................................... 109losartan potassium ...........................39losartan potassium-hctz ................... 39Lotemax ........................................ 114Lotemax SM ..................................114loteprednol etabonate .................... 114lovastatin ..........................................37loxapine succinate ........................... 51Lumigan ........................................ 115lung perform peak flow meter ........ 101Lynparza ....................................... 119Lyrica CR .............................. 119, 122Lysodren .........................................44mafenide acetate ............................. 73MagneBind 400 .............................104malathion ......................................... 79maprotiline hcl ..................................29Marnatal-F .....................................106

Marplan ........................................... 29Matulane ......................................... 47Matzim LA ....................................... 60Mavenclad (10 Tabs) ....................106Mavenclad (4 Tabs) ......................106Mavenclad (5 Tabs) ......................106Mavenclad (6 Tabs) ......................106Mavenclad (7 Tabs) ......................106Mavenclad (8 Tabs) ......................106Mavenclad (9 Tabs) ......................106Mavyret ........................................... 92Maxidex .........................................114Mayzent .........................................123Mayzent Starter Pack ...................123MB HydroGel .................................. 78me/naphos/mb/hyo1 ...................... 129meclofenamate sodium ....................13MediSense Glucose Ketone Contr ............................................... 99Medisense Hi/Mid/Low Control .....99Medisense High/Low Control ........99Medisense Mid Control ..................99Medrol ............................................. 65medroxyprogesterone acetate ....... 120mefenamic acid ................................13mefloquine hcl ..................................42megestrol acetate .................... 48, 120meijer alcohol swabs ........................96Mekinist ...........................................45Mektovi ............................................45meloxicam ........................................13melphalan ........................................ 47memantine hcl ................................122memantine hcl er ........................... 122Menactra ....................................... 131Menest .............................................87Menostar ......................................... 87Menveo ..........................................131meperidine hcl ..................................16meprobamate ...................................20mercaptopurine ................................ 44mesalamine ......................................88mesalamine er ................................. 88mesalamine-cleanser .......................88Mesnex ............................................48Metadate ER ................................... 11metaproterenol sulfate ..................... 22metaxalone .................................... 109metformin hcl ................................... 31metformin hcl er ............................... 31methadone hcl ................................. 16Methadone HCl Intensol ................ 16Methadose ...................................... 16methamphetamine hcl ......................10methazolamide .................................82methenamine hippurate ................. 129methenamine mandelate ............... 129Methergine ....................................116methimazole ...................................125methitest .......................................... 18

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methocarbamol .............................. 109methotrexate .................................... 44methotrexate sodium ....................... 44methoxsalen rapid ............................72methscopolamine bromide .............129methyldopa ...................................... 40methyldopa-hydrochlorothiazide ...... 38methylergonovine maleate .............116methylphenidate hcl ......................... 11methylphenidate hcl er .....................11methylphenidate hcl er (cd) ..............11methylphenidate hcl er (la) ...............11methylprednisolone ..........................66methyltestosterone ...........................18metoclopramide hcl ....................87, 88metolazone ...................................... 82metoprolol succinate er ....................58metoprolol tartrate ............................58metoprolol-hydrochlorothiazide ........40metronidazole .................... 41, 79, 132mexiletine hcl ................................... 21miconazole 3 ..................................132Microchamber .............................. 102Microdot Control High/Low ...........99Microlife Digital Peak Flow ..........101Microspacer ..................................102midodrine hcl ..................................133Migergot ........................................103miglitol ..............................................31miglustat ...........................................91Millipred .......................................... 66Millipred DP .................................... 66Millipred DP 12-Day ....................... 66Mimvey ............................................86MimyX ............................................. 78mineral oil .........................................94mineral oil heavy .............................. 94mineral oil light ................................. 80Mini Wright Peak Flow Meter ...... 101Minitran ........................................... 19minocycline hcl ...............................125minocycline hcl er .......................... 125Minolira ......................................... 125minoxidil ........................................... 40mirtazapine ...................................... 29misoprostol .....................................129m-natal plus ................................... 106modafinil ...........................................11moexipril hcl ..................................... 38mometasone furoate ................ 75, 110Mondoxyne NL ............................. 125monsels ferric subsulfate ................. 92montelukast sodium ......................... 23Monurol .........................................129Morgidox .......................................125morphine sulfate .............................. 17morphine sulfate (concentrate) ........ 16morphine sulfate er .......................... 17morphine sulfate er beads ............... 16Motofen ........................................... 34

Movantik ......................................... 88MoviPrep .........................................94moxifloxacin hcl ........................87, 112moxifloxacin hcl (2x day) ................112Mulpleta .......................................... 91Multaq ............................................. 21mupirocin ......................................... 71mupirocin calcium ............................ 71Muse ................................................61M-Vit .............................................. 106MX-Sol ...........................................117MX-Sol Blend ................................117MX-Sol Blend SF .......................... 117MX-Sol SF ..................................... 117MX-Sol Suspend ...........................117mycophenolate mofetil ..................... 57mycophenolate sodium .................... 57Mydayis ...........................................10MyGlucoHealth Control ................. 99Myleran ........................................... 44Mynatal ..........................................107Mynatal Advance ..........................106mynatal plus ...................................107mynatal-z ....................................... 107mynate 90 plus ...............................107Myorisan ......................................... 70Myrbetriq ...............................129, 130Mysoline ..........................................26Mytesi ..............................................34nabumetone ..................................... 14nadolol ............................................. 58naftifine hcl .......................................71Naftin ...............................................71Nalfon ..............................................14naltrexone hcl ...................................34Namzaric ......................................... 28Naprelan ..........................................14naproxen .......................................... 14naproxen dr ......................................14naproxen sodium ............................. 14naproxen sodium er ......................... 14naproxen-esomeprazole .................. 13naratriptan hcl ................................ 103Narcan .............................................34NataChew ......................................107Natacyn ......................................... 112Natalvit .......................................... 107Natazia ............................................ 65nateglinide ........................................33Natpara ............................................85Nature-Throid ............................... 126Nayzilam ......................................... 25Nebusal ........................................... 67nefazodone hcl .........................29, 124Neocera ...........................................78neomycin sulfate .............................. 11neomycin-bacitracin zn-polymyx ....112neomycin-polymyxin-dexameth ..... 114neomycin-polymyxin-gramicidin .....113neomycin-polymyxin-hc ......... 114, 115

NeoNatal Plus ...............................107Neo-Polycin .................................. 113Neo-Polycin HC ............................ 114Neoral ..............................................56Neosalus ......................................... 78Neosalus CP ................................... 78Neo-Synalar .................................... 70Nerlynx ............................................46Nestabs ......................................... 107Nestabs DHA ................................ 107Nestabs One ................................. 108Neuac .............................................. 69Neupro ............................................ 49Neurontin ........................................ 26Neutek 2Tek Control ...................... 99Neutrogena ..................................... 80Neutrogena Triple Moisture .......... 80Nevanac ........................................ 113nevirapine ........................................ 54nevirapine er .................................... 54NexAVAR ........................................ 45NexIUM ..........................................128niacin er (antihyperlipidemic) ........... 38nicardipine hcl .................................. 60Nice Distilled Water ..................... 117nifedipine ..........................................60nifedipine er ..................................... 60nifedipine er osmotic release ........... 60Nilandron ........................................ 44nilutamide .........................................44nimodipine ........................................61Ninlaro .............................................45nisoldipine er ....................................61nitisinone ..........................................84Nitro-Bid ..........................................19Nitro-Dur ......................................... 19nitrofurantoin .................................. 129nitrofurantoin macrocrystal .............129nitrofurantoin monohyd macro ....... 129nitroglycerin ......................................20nitroglycerin er ................................. 20NitroMist ......................................... 20Nitro-Time ....................................... 20Nityr .................................................84Niva-Plus .......................................107Nivatopic Plus ................................ 78Nolix ................................................ 75Norditropin FlexPro ....................... 84norethindrone acetate .................... 120norethindrone-eth estradiol .............. 86norethin-eth estradiol-fe ................... 65norgestim-eth estrad triphasic ..........65Noritate ........................................... 79Norpace CR .................................... 21nortriptyline hcl .................................30Norvir .............................................. 53Nourianz ..........................................10Nova Max Plus Glu/Ket Control .... 99NovoLIN 70/30 ................................ 32NovoLIN N .......................................32

142

NovoLIN N FlexPen ........................32NovoLIN R .......................................32NovoLIN R FlexPen ........................32NovoLOG ........................................ 32NovoLOG FlexPen ......................... 32NovoLOG Mix 70/30 ....................... 32NovoLOG Mix 70/30 FlexPen ........ 32NovoLOG PenFill ........................... 32Noxafil ............................................. 35Nubeqa ............................................44Nucala ............................................. 93NuCort .............................................76Nucynta ...........................................17Nucynta ER .....................................17Nuedexta .......................................122NuLev ............................................ 128Nuplazid .......................................... 50Nutraseb ......................................... 73Nutropin AQ NuSpin 10 ................. 84Nutropin AQ NuSpin 20 ................. 84Nutropin AQ NuSpin 5 ................... 84NuvaRing ........................................ 65Nuvessa ........................................ 132Nuzyra ............................................. 11Nyamyc ........................................... 71nystatin ...............................35, 71, 105nystatin-triamcinolone ...................... 71Nystop .............................................71OB Complete ................................ 107OB Complete One ........................ 107OB Complete Petite ..................... 107OB Complete Premier ..................107OB Complete/DHA ....................... 107Obstetrix DHA .............................. 107Obstetrix EC ................................. 107Obstetrix One ............................... 109Obtrex ........................................... 107Obtrex DHA ...................................107O-Cal Prenatal .............................. 107Ocaliva ............................................ 87octreotide acetate ............................ 85Odactra ......................................... 105Odefsey ...........................................53Odomzo ...........................................44Ofev ............................................... 123ofloxacin ...........................87, 112, 115Okebo ............................................125olanzapine ........................................51olanzapine-fluoxetine hcl ............... 123olive oil ............................................. 64olmesartan medoxomil .....................39olmesartan medoxomil-hctz ............. 39olmesartan-amlodipine-hctz .............39olopatadine hcl .......................110, 112omega-3-acid ethyl esters ................36omeprazole .................................... 128Omnaris ........................................ 110Omnitrope .......................................84On Call Express Glucose Contr ....99On Call Plus Glucose Control .......99

On Call Vivid Glucose Control ......99ondansetron ..................................... 35ondansetron hcl ............................... 35OneTouch Ultra Control ................ 99OneTouch Verio ....................... 81, 99Onexton .......................................... 69Onfi ..................................................25Onzetra Xsail ................................ 103opium ............................................... 34Opsumit .......................................... 62OptiChamber Advantage-Lg Mask .............................................. 102OptiChamber Advantage-Med Mask .............................................. 102OptiChamber Advantage-Sm Mask .............................................. 102OptiChamber Diamond ................102OptiChamber Diamond-Lg Mask 102OptiChamber Diamond-Md Mask102OptiChamber Diamond-Sm Mask....................................................... 102OptiChamber Face Mask-Large .. 102OptiChamber Face Mask-Medium....................................................... 102OptiChamber Face Mask-Small .. 102OptiHaler .......................................102OptumRx Glucose Control ............99Ora-Blend ......................................117Ora-Blend SF ................................ 117Oracit ...............................................89Orafate .......................................... 105Oral Mix .........................................117Oral Mix SF ................................... 117oral suspend .................................. 117oral suspending compound plus .... 117oral syrup ....................................... 117oral syrup sf ................................... 117Oralair ........................................... 105Oralone ................................. 106, 125Ora-Plus ........................................ 118Ora-Sweet ..................................... 118Ora-Sweet SF ................................118Oravig ............................................105Orenitram ........................................61Orfadin ............................................ 84organic coconut oil ........................... 64Orilissa ............................................83Orkambi .......................................... 68orphenadrine citrate er ...................110oscimin ...........................................128oscimin sr .......................................128oseltamivir phosphate ...................... 56Osmolex ER ....................................48OsmoPrep .......................................94Osphena ..........................................85Otezla ............................................ 119Otovel ............................................115Ovace Plus ......................................73oxaprozin ......................................... 14Oxaydo ............................................17

oxazepam ........................................ 20Oxbryta ........................................... 91oxcarbazepine ..................................26oxiconazole nitrate ........................... 77Oxistat .............................................77Oxsoralen Ultra .............................. 72Oxtellar XR ......................................26oxybutynin chloride ........................ 130oxybutynin chloride er .................... 130oxycodone hcl .................................. 17oxycodone hcl er ..............................17oxycodone-acetaminophen ........17, 18oxycodone-aspirin ............................18oxycodone-ibuprofen ....................... 18OxyCONTIN .................................... 17oxymorphone hcl ..............................17Ozempic (0.25 or 0.5 MG/DOSE) ... 32Ozempic (1 MG/DOSE) ...................32Ozobax .......................................... 110Pacerone .........................................21Palforzia (12 MG Daily Dose) ........ 59Palforzia (120 MG Daily Dose) ...... 59Palforzia (160 MG Daily Dose) ...... 59Palforzia (20 MG Daily Dose) ........ 59Palforzia (200 MG Daily Dose) ...... 59Palforzia (240 MG Daily Dose) ...... 59Palforzia (3 MG Daily Dose) .......... 59Palforzia (300 MG Maintenance) ... 59Palforzia (300 MG Titration) .......... 59Palforzia (40 MG Daily Dose) ........ 59Palforzia (6 MG Daily Dose) .......... 59Palforzia (80 MG Daily Dose) ........ 59Palforzia Initial Escalation .............59paliperidone er ................................. 50Palynziq .......................................... 85Pancreaze ....................................... 81Pandel ............................................. 76PanOxyl Creamy Wash ..................70Panretin ...........................................72pantoprazole sodium ......................128paricalcitol ........................................ 85Paroex ........................................... 105paromomycin sulfate ........................11paroxetine hcl ...................................30paroxetine hcl er .............................. 30paroxetine mesylate .......................123Paser ............................................... 43Paxil .................................................30Pazeo .............................................112PCCA Sweet-SF ............................118PCCA Syrup Vehicle .................... 118PCCA-Plus .................................... 118Peak Air Peak Flow Meter ........... 101peak flow meter universal rang ...... 101peanut oil ......................................... 64Pediarix ......................................... 127Pedvax HIB ................................... 131peg-3350/electrolytes .......................94Peganone ........................................28Pegasys .......................................... 55

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Pegasys ProClick ...........................55PegIntron ........................................ 55PEG-Prep ........................................ 94Pemazyre ........................................ 43penicillamine .................................... 56penicillin v potassium ..................... 116Pennsaid ......................................... 71Pentacel ........................................ 127Pentasa ........................................... 88pentazocine-naloxone hcl ................ 18pentetate calcium trisodium ............. 34pentetate zinc trisodium ................... 34pentoxifylline er ................................ 90Perforomist .....................................22perindopril erbumine ........................ 38Periogard ...................................... 105permethrin ........................................79perphenazine ................................... 51perphenazine-amitriptyline .............122Personal Best Full Range ............101Personal Best Low Range ...........101Pertzye ............................................ 81Pexeva .............................................30Phacid ............................................. 80Pharmacist Choice Alcohol .......... 96Phenadoz ........................................ 36Phenazo .......................................... 90phenazopyridine hcl ......................... 90phenelzine sulfate ............................ 29phenobarbital ................................... 92phenobarbital-belladonna alk .........127Phenohytro ................................... 127phenol .............................................. 52phenoxybenzamine hcl .................... 39phenylephrine hcl ...........................111Phenytek ......................................... 28phenytoin ......................................... 28Phenytoin Infatabs .........................28phenytoin sodium extended ............. 28Phoslyra ..........................................89Phospha 250 Neutral ................... 104Phosphasal ...................................129Phospholine Iodide ......................112phosphorous .................................. 104Phospho-Trin 250 Neutral ........... 104phytonadione ................................. 133Picato .............................................. 72Pifeltro .............................................54Piko 1 ............................................ 101pilocarpine hcl ........................ 106, 112pimecrolimus ....................................78pimozide .........................................123Pimtrea ............................................64pindolol .............................................58pioglitazone hcl ................................ 33pioglitazone hcl-glimepiride ..............33pioglitazone hcl-metformin hcl ......... 33Piqray (200 MG Daily Dose) ........ 118Piqray (250 MG Daily Dose) ........ 119Piqray (300 MG Daily Dose) ........ 119

piroxicam ..........................................14Plegridy .........................................121Plegridy Starter Pack ...................121Plenvu ............................................. 94Plexion Cleansing Cloth ................69Pneumovax 23 ..............................131pnv folic acid + iron ........................ 107pnv prenatal plus multivit+dha ....... 107pnv prenatal plus multivitamin ........107pnv tabs 29-1 ................................. 107pnv-dha .......................................... 109pnv-dha+docusate ......................... 109pnv-omega ..................................... 107pnv-select .......................................107Pocket Chamber ...........................102Pocket Peak Flow Meter .............. 101Pocket Spacer .............................. 102PocketChem EZ Control ................99Pocketpeak Peak Flow Meter ......101podocon ........................................... 77podofilox ...........................................77Polycin .......................................... 113polymyxin b-trimethoprim ...............113polypeg .......................................... 118Pomalyst ......................................... 45pot bicarb-pot chloride ................... 104potassium bicarbonate ...................104potassium chloride ......................... 105potassium chloride crys er ............. 104potassium chloride er .............104, 105potassium citrate er ..........................89potassium citrate-citric acid ..............89pr benzoyl peroxide ..........................70PR Benzoyl Peroxide Wash .......... 70PR Cream ........................................78PR Natal 400 ................................. 108PR Natal 400 ec ............................ 108PR Natal 430 ................................. 108PR Natal 430 ec ............................ 108Praluent .........................................116pramipexole dihydrochloride ............ 49pramipexole dihydrochloride er ........49Pramosone ..................................... 80prasugrel hcl .................................... 91pravastatin sodium ...........................37praziquantel ..................................... 19prazosin hcl ......................................40Precision Glucose Control ..........100Precision Glucose Control Soln . 100Precision Glucose Ketone Contr 100Precision Glucose/Ketone Contr 100Pred Mild .......................................114Pred-G ........................................... 114Pred-G S.O.P. ............................... 114prednicarbate ................................... 76prednisolone .................................... 66prednisolone acetate ......................115prednisolone acetate p-f ................ 115

prednisolone sodium phosphate................................................. 66, 115prednisone ....................................... 66PredniSONE Intensol .....................66Prefest .............................................86pregabalin ........................................ 26Premarin ................................. 87, 132premium lidocaine ............................77Premphase ......................................86Prempro .......................................... 86prena 1 true ....................................109prena1 ............................................109prena1 pearl ...................................107prenaissance ..................................109prenaissance plus .......................... 109prenatal .......................................... 107Prenatal + DHA .............................109prenatal 19 ..................................... 107prenatal plus iron ........................... 107prenatal vitamin plus low iron .........107Prenatal-U ..................................... 107Prenate ..................................109, 120Prenate DHA ................................. 109Prenate Elite ................................. 107Prenate Enhance ..........................109Prenate Essential ......................... 109Prenate Mini ..................................109Prenate Pixie ................................ 109Prenate Restore ........................... 109Prepidil ..........................................116preplus ........................................... 107Prepopik ..........................................94Presera ............................................78Prestalia .......................................... 38pretab .............................................107Pretomanid ..................................... 43Prevalite .......................................... 37Prevnar 13 .....................................131Prevymis ......................................... 55Prezcobix ........................................ 53Prezista ........................................... 53Priftin ...............................................43PriLOSEC ......................................128PrimaCare ..................................... 107primaquine phosphate ..................... 42primidone ......................................... 26Primlev ............................................ 18Primsol ............................................41pro comfort alcohol .......................... 96pro comfort spacer adult ................ 102pro comfort spacer child .................102ProAir Digihaler ..............................22ProAir HFA ......................................22ProAir RespiClick ...........................22probenecid ....................................... 90prochlorperazine .............................. 51prochlorperazine maleate ................ 51Procysbi ..........................................89Prodigy Control Solution ............ 100progesterone micronized ............... 120

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Prograf ............................................ 57Prolensa ........................................113Promacta .........................................91promethazine hcl ..............................36promethazine-codeine ..................... 67promethazine-dm ............................. 67promethazine-phenyleph-codeine ....68promethazine-phenylephrine ........... 67Promethegan .................................. 36Promiseb .........................................73propafenone hcl ............................... 21propafenone hcl er ........................... 21propantheline bromide ................... 129proparacaine hcl ............................ 113propranolol hcl ................................. 58propranolol hcl er ............................. 58propranolol-hctz ............................... 40propylthiouracil ...............................125ProQuad ........................................131Pro-Red AC .....................................68Prostin E2 ..................................... 116ProThelial ......................................105Protonix ........................................ 128protriptyline hcl .................................30Proventil HFA ................................. 22Provida OB ................................... 107PruClair ........................................... 78PruMyx ............................................ 78pseudoeph-bromphen-dm ................67psorcon ............................................ 76Pulmicort Flexhaler ........................24PulmoSal .........................................67Pulmozyme ................................... 124purified water ................................. 118Purixan ............................................44px purified water .............................118pyrazinamide ....................................43pyridostigmine bromide ....................42pyridostigmine bromide er ................42pyrimethamine ................................. 63pyrogallic acid .................................. 77Qbrelis .............................................38Qbrexza ...........................................79qc alcohol swabs ..............................96qc castor oil ......................................64qc glycerin ........................................76qc mineral oil heavy ......................... 94qc sweet oil ...................................... 64Qnasl ............................................. 110Qnasl Childrens ........................... 110Qtern ............................................. 124Quadracel ..................................... 127quazepam ........................................ 92Qudexy XR ......................................26quetiapine fumarate ......................... 51quetiapine fumarate er ..................... 50QuickTek Control Solution ..........100QuilliChew ER ................................ 11quinapril hcl ......................................38quinapril-hydrochlorothiazide ........... 38

quinidine gluconate er ......................21quinidine sulfate ............................... 21quinine sulfate ..................................42Quintet Control High/Normal ...... 100Qvar RediHaler ............................... 24ra alcohol swabs .............................. 96RA Crystal Lake Dist Water .........118ra glycerin ........................................ 76ra isopropyl alcohol wipes ................80ra mineral oil .................................... 94rabeprazole sodium ....................... 129Ragwitek ......................................... 59raloxifene hcl ....................................85ramelteon ......................................... 93ramipril ............................................. 38ranolazine er .................................... 19Rapamune .......................................57rasagiline mesylate .......................... 48Ravicti ............................................. 85Rayaldee ......................................... 85Rayos .............................................. 66reality swabs .................................... 96Rebif .............................................. 121Rebif Rebidose .............................121Rebif Rebidose Titration Pack .... 121Rebif Titration Pack ..................... 122Recedo ............................................ 79Recombivax HB ............................132Rectiv .............................................. 19RefuAH Plus Glucose Control .... 100Regranex .........................................81Relenza Diskhaler .......................... 56ReliOn Alcohol Swabs ...................96ReliOn Ketone ................................ 81ReliOn Ketone Test ........................81Relistor ............................................88relnate dha ..................................... 108Relpax ........................................... 103remigen ............................................ 78repaglinide ....................................... 33Repatha .........................................116Repatha Pushtronex System ...... 116Repatha SureClick ....................... 116Restasis ........................................ 113Restora RX ................................33, 34Retin-A Micro Pump .......................70Retrovir ........................................... 54Revatio ............................................ 62Revlimid .......................................... 57Rexulti ............................................. 51Reyataz ........................................... 54ribavirin ............................................ 55Ridaura ............................................13rifabutin ............................................ 43Rifamate ..........................................42rifampin ............................................ 43Rifater ..............................................42Rightest GC300 Control .............. 100riluzole ............................................111rimantadine hcl .................................55

Rinvoq .............................................12Riomet .............................................31Riomet ER .......................................31risedronate sodium .......................... 83risperidone ....................................... 50RiteFlo ...........................................102ritonavir ............................................ 54rivastigmine ....................................121rivastigmine tartrate ....................... 121rizatriptan benzoate ....................... 103R-Natal OB .................................... 109ropinirole hcl .....................................49ropinirole hcl er ................................ 49Rosadan ..........................................79rosuvastatin calcium ........................ 37Rotarix ...........................................132RotaTeq .........................................132Roweepra XR ..................................27Rozlytrek .........................................43Rubraca .........................................119Ruzurgi ............................................42Rybelsus ......................................... 32RyClora ........................................... 36Rydapt .............................................45Rytary ..............................................49Sabril ............................................... 27safflower oil ...................................... 64Saizen ..............................................84Saizenprep ......................................84salicylic acid ..................................... 77salicylic acid er .................................77salicylic acid wart remover ............... 77salsalate ...........................................15Samsca ........................................... 85Sancuso .......................................... 35SandIMMUNE ..................................56SandoSTATIN ................................. 85Santyl .............................................. 76Saphris ............................................50saps care alcohol prep .....................96saps health alcohol prep .................. 96saps health care alcohol prep .......... 96Savella ...........................................121Savella Titration Pack ..................121sb alcohol prep .................................96scarcin ..............................................79scarsilk ............................................. 79scopolamine .....................................35Sebuderm ....................................... 78Seconal ........................................... 92Seebri Neohaler ..............................23Select-OB ......................................108Select-OB+DHA ............................109selegiline hcl .................................... 48selenium sulfide ............................... 73Selzentry ......................................... 53Semprex-D ...................................... 67se-natal 19 ..................................... 108Sensipar ..........................................83Serevent Diskus ............................. 22

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Sernivo ............................................76Serostim ..........................................84sertraline hcl .....................................30sesame oil ........................................64sevelamer carbonate ....................... 89sevelamer hcl ...................................89SfRowasa ........................................88Shopko Alcohol Swabs ................. 96Signifor ........................................... 85Siklos .............................................. 91sildenafil citrate ................................ 62Silenor .............................................92silodosin ........................................... 89silver nitrate ......................................73silver sulfadiazine .............................73Simbrinza ......................................111simple syrup ...................................118Simponi ...........................................12simvastatin ....................................... 37sirolimus ...........................................57Sirturo ............................................. 43Sitavig ............................................. 55Sivextro ...........................................41Sklice ...............................................79Skyrizi (150 MG Dose) ................... 72Slynd ............................................... 65sm alcohol prep ................................96sm benzoin tincture ..........................80sm glycerin .......................................76sm mineral oil ...................................94sm sweet oil ..................................... 64Smartest Control Medium ........... 100sod citrate-citric acid ........................ 89sodium chloride ................................67sodium phenylbutyrate .....................85sodium polystyrene sulfonate .. 57, 120sodium saccharin ............................. 81sodium sulfacetamide ...................... 73sodium sulfacetamide wash .............73Solartek Glucose Control ............100solifenacin succinate ......................130Soliqua ............................................ 93Soltamox .........................................44Solus V2 Control .......................... 100Somavert .........................................83sorbitol ..................................... 94, 118Soriatane .........................................72Sorine ..............................................58sotalol hcl ......................................... 58sotalol hcl (af) ...................................58Sotylize ........................................... 58soybean oil .......................................64spg supposi-base ...........................118spinosad ...........................................79Spiriva HandiHaler ......................... 23Spiriva Respimat ............................23spironolactone ..................................82spironolactone-hctz ..........................82Sprix ................................................ 14Sprycel ............................................ 46

SPS ..........................................57, 120SSD ..................................................73SSKI .................................................67sss 10-5 ........................................... 69stavudine ..........................................54Stelara ............................................. 72Stendra ............................................62Stimate ............................................ 86Stiolto Respimat .............................21Stivarga ...........................................45Striant ..............................................18Stribild .............................................53Striverdi Respimat ......................... 22Suboxone ........................................18Subsys ............................................ 17Subvenite ........................................27Subvenite Starter Kit-Blue ............ 27Subvenite Starter Kit-Green ..........27Subvenite Starter Kit-Orange ........27Sucraid ............................................81sucralfate ....................................... 128sulconazole nitrate ........................... 77sulfacetamide sodium .............. 73, 115sulfacetamide sodium (acne) ........... 69sulfacetamide sodium-sulfur ............ 69sulfacetamide-prednisolone ........... 114sulfacetamide-sulfur in urea .............69SulfaCleanse 8/4 ............................ 69sulfadiazine .................................... 125sulfamethoxazole-trimethoprim ........41sulfamez wash ................................. 69Sulfamylon ......................................73sulfasalazine .................................... 88Sulfatrim Pediatric ......................... 41sulindac ............................................14sumatriptan .................................... 103sumatriptan succinate .................... 103sumatriptan succinate refill ............ 103Sunosi ............................................. 83Supposiblend ............................... 118Supposi-Plex R36 .........................118Supposi-Plex V33 .........................118Suprax .............................................63supreme ii high/low control ............ 100Suprep Bowel Prep Kit .................. 94sure comfort alcohol prep ................ 96Sure-Prep Alcohol Prep .................96SureStep Glucose Control .......... 100SureStep Pro High Glucose ........ 100SureStep Pro Low Glucose .........100SureStep Pro Normal Glucose ....100SuspendRx w/BitterBloc Sweet ..118SuspendRx w/BitterBloc Unsweet ........................................ 118suspension vehicle .........................118Sustiva ............................................ 54Sutent ..............................................45sweet oil ........................................... 64sweetening suspending compound118Sylatron ...........................................47

Symax Duotab .............................. 128Symax-SL ......................................128Symax-SR ..................................... 128Symbicort ....................................... 22Symdeko ......................................... 68Symfi ............................................... 53Symfi Lo ..........................................53SymlinPen 120 ................................31SymlinPen 60 ..................................31Sympazan ....................................... 25Symproic .........................................88Symtuza .......................................... 53Syndros ...........................................35Synera ............................................. 80Synjardy ........................................124Synjardy XR ..................................124Synthroid ...................................... 126Syprine ............................................56syrpalta .......................................... 118Syrpalta (Red) ...............................118SyrSpend SF .................................118syrup nf .......................................... 118syrup vehicle .................................. 118syrup vehicle sf .............................. 118Tabloid ............................................ 44Taclonex ......................................... 81tacrolimus ...................................57, 78tadalafil .............................................62tadalafil (pah) ................................... 62Tafinlar ............................................ 44Tagrisso .......................................... 46Tai Doc Control ............................ 100Talzenna ........................................119Tamiflu ............................................ 56tamoxifen citrate ...............................44tamsulosin hcl .................................. 89Tarceva ........................................... 46Targretin ................................... 48, 80Taron-C DHA ................................ 108Taron-Crystals ................................89Taron-Prex .................................... 109Tasigna ........................................... 46Tavalisse .......................................124Taytulla ........................................... 65tazarotene ........................................ 73Tazorac ........................................... 73Taztia XT ......................................... 61Tazverik ...........................................43TDVAX ...........................................127Tecfidera ....................................... 122TEGretol ..........................................27TEGretol-XR ....................................27Tegsedi ........................................... 52Tekturna HCT ................................. 40Telcare Glucose Control ............. 100telmisartan ....................................... 39telmisartan-amlodipine .....................39telmisartan-hctz ................................39temazepam ...................................... 92Temodar ..........................................47

146

temozolomide ...................................47Tencon ............................................ 15Tenivac ..........................................127tenofovir disoproxil fumarate ............55Tenoretic 100 ..................................40Tenoretic 50 ....................................40Tenormin .........................................58terazosin hcl .....................................40terbinafine hcl ...................................35terbutaline sulfate .............................22terconazole .................................... 132testosterone ..................................... 19testosterone cypionate .....................18testosterone enanthate .................... 18tetrabenazine ................................. 121tetracaine hcl ..................................113tetracycline hcl ............................... 125Tetrix ............................................... 78Texacort .......................................... 76tgt alcohol swabs ............................. 96Thalomid ......................................... 56Theo-24 ........................................... 24theophylline ......................................24theophylline er ..................................24Thiola .............................................. 90Thiola EC ........................................ 90thioridazine hcl ................................. 51thiothixene ........................................51thrivite rx ........................................ 108tiagabine hcl .....................................27Tibsovo ........................................... 93Tiglutik .......................................... 111timolol maleate .........................58, 111Timoptic Ocudose ........................111tinidazole ..........................................41Tirosint ..........................................126Tirosint-SOL ................................. 126Tivicay .............................................53tizanidine hcl .................................. 110Tobi ................................................. 11Tobi Podhaler ................................. 11TobraDex ...................................... 114TobraDex ST .................................114tobramycin ............................... 11, 112tobramycin-dexamethasone ...........114Tobrex ........................................... 112Tolak ................................................72tolbutamide ...................................... 33tolcapone ......................................... 48tolmetin sodium ................................14tolterodine tartrate ..........................130Topamax ......................................... 27Topamax Sprinkle .......................... 27Topex Topical Anesthetic ........... 105topiramate ........................................ 27topiramate er ....................................27toremifene citrate ............................. 44torsemide ......................................... 82Toujeo Max SoloStar ..................... 32Toujeo SoloStar ............................. 32

Toviaz ............................................130Tracleer ........................................... 62tramadol hcl ..................................... 17tramadol hcl er ................................. 17tramadol hcl er (biphasic) .................17tramadol-acetaminophen ................. 18trandolapril ....................................... 38trandolapril-verapamil hcl er .............38tranexamic acid ................................91tranylcypromine sulfate .................... 29Travatan Z .....................................115trazodone hcl ........................... 29, 124Trecator ...........................................43Trelegy Ellipta ................................ 22Tremfya ........................................... 72tretinoin ...................................... 48, 70tretinoin microsphere ....................... 70tretinoin microsphere pump ............. 70Trexall ............................................. 44Trezix ...............................................15triamcinolone acetonide ... 76, 106, 125triamterene .......................................82triamterene-hctz ............................... 82Trianex ............................................ 76triazolam .......................................... 92TriCare .......................................... 108TriCare Prenatal DHA ONE ..........108Tri-Chlor ..........................................73tricitrates .......................................... 89Triderm ............................................76trientine hcl .......................................56trifluoperazine hcl .............................51trifluridine ....................................... 113trihexyphenidyl hcl ........................... 48Trikafta ............................................ 68Trileptal ........................................... 27Tri-Lo-Estarylla ...............................65Tri-Lo-Marzia .................................. 65Tri-Lo-Sprintec ............................... 65TriLyte ............................................. 94trimethobenzamide hcl .....................35trimethoprim ..................................... 41trimipramine maleate ....................... 30trinatal rx 1 ..................................... 108Trintellix .................................. 29, 124tristart dha ...................................... 109tri-tabs dha ..................................... 108Triumeq ...........................................53Triveen-Duo DHA ......................... 108Tri-VyLibra Lo .................................65Trizivir ............................................. 53Trokendi XR ....................................27tropicamide .................................... 111trospium chloride ............................130trospium chloride er ....................... 130true comfort alcohol prep pads ........ 96True Metrix Level 1 ...................... 100True Metrix Level 2 ...................... 100True Metrix Level 3 ...................... 100TrueControl Glucose Cont Lev 0 100

TrueControl Glucose Cont Lev 1 100Trulance .......................................... 64Trulicity ........................................... 32Trumenba ......................................131Truvada ........................................... 53TruZone Peak Flow Meter ........... 101Tudorza Pressair ............................23Tukysa .............................................46Turalio ............................................. 46Tusnel Pediatric ............................. 67TussiCaps .......................................67Tuzistra XR ..................................... 67Twinrix .......................................... 131Tybost ............................................. 51Tykerb ............................................. 46Tymlos ............................................ 85Tyvaso .............................................61Tyvaso Refill ...................................61Tyvaso Starter ................................ 62Ubrelvy ............................................60Uceris .............................................. 19UltiCare Alcohol Swabs .................96ultilet alcohol swabs ......................... 96ultra-care alcohol prep pads ............ 96Ultraswim ........................................80Ultraswim Ultra Repair .................. 80UltraTRAK PRO Control .............. 100UltraTRAK Ultimate Control ........100Ultravate ..........................................76Unistrip Control ............................100Unithroid ....................................... 126Uptravi ...........................................123urea ..................................................76Uredeb .............................................76Urelle ............................................. 129Uretron D/S ................................... 129Uribel .............................................129Urimar-T ........................................ 129urin ds ............................................ 129uro-mp ............................................129ursodiol ............................................ 87Uryl ................................................ 129Ustell ............................................. 129Utira-C ........................................... 129Utrona-C ........................................129valacyclovir hcl .................................55Valchlor ...........................................72Valcyte ............................................ 55valganciclovir hcl ..............................55valproic acid ..................................... 28valsartan .......................................... 39valsartan-hydrochlorothiazide .......... 39valved holding chamber ................. 102Vanatol LQ ...................................... 15Vanatol S .........................................15vancomycin hcl ................................ 90Vandazole ..................................... 132Vanoxide-HC ...................................69Vaqta ............................................. 132vardenafil hcl ....................................62

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Varivax .......................................... 132Vascepa .......................................... 36Vecamyl .......................................... 40Velphoro ......................................... 89Veltassa .................................. 57, 120Veltin ............................................... 69Vemlidy ........................................... 55Venclexta ........................................ 43Venclexta Starting Pack ................ 43Venelex ........................................... 81venlafaxine hcl ................................. 30venlafaxine hcl er ............................. 30Ventavis .......................................... 62Ventolin HFA .................................. 22verapamil hcl ....................................61verapamil hcl er ................................61verasens glucose control ............... 100Verdeso ...........................................76Veregen ...........................................70Versacloz ........................................ 50VersaFree ......................................118VersaPlus ......................................118Verzenio .......................................... 68Viberzi ............................................. 93Vibramycin ....................................125Victory Control Level 1/2 .............100Victoza ............................................ 32vigabatrin ......................................... 27Vigadrone ....................................... 27Viibryd .....................................29, 124Viibryd Starter Pack ...............29, 124Vilamit MB .....................................129Vimpat ............................................. 27Vinate Care ................................... 108Vinate II ......................................... 108Vinate M ........................................ 108Vinate One .................................... 108Viokace ........................................... 81viorele .............................................. 64Viracept ...........................................54Viramune .........................................54Viramune XR ...................................54Viread .............................................. 55virt-c dha ........................................ 108virt-nate dha ................................... 108virt-phos 250 neutral ...................... 104virt-pn dha ...................................... 109virt-pn plus ..................................... 108virtussin a/c ...................................... 67virtussin dac ..................................... 67Vistogard ........................................ 34Vitafol Ultra ...................................109Vitafol-OB ..................................... 108Vitafol-OB+DHA ........................... 109Vitafol-One ....................................109VitaMedMD RediChew Rx ............109vitamin d (ergocalciferol) ................133VitaPearl ........................................108VitaTrue .........................................109Vitrakvi ............................................ 43

Viva DHA .......................................108Vizimpro ..........................................46vol-plus ...........................................108vol-tab rx ........................................ 108voriconazole ...............................35, 36Vortex Valved Holding Chamber 102Vosevi ............................................. 92Votrient ........................................... 46vp-heme ob + dha ..........................108Vraylar .............................................50Vumerity ........................................122Vumerity (Starter) .........................122Vyleesi ...........................................103Vyndamax ..................................... 127Vyndaqel ....................................... 127Vyvanse .......................................... 10Wakix ...............................................92warfarin sodium ................................24Watchhaler ....................................102Webcol Alcohol Prep Large .......... 96Webcol Alcohol Prep Medium ...... 96Westhroid ..................................... 126wheat germ oil ................................133Witepsol ........................................ 118Wixela Inhub ...................................22WP Thyroid ................................... 126Xadago ............................................ 48Xalkori ............................................. 46Xarelto .............................................24Xarelto Starter Pack .......................24Xatmep ............................................ 44Xeljanz .............................................12Xeljanz XR .......................................12Xeloda ............................................. 44Xenazine ....................................... 121Xenleta .......................................... 119Xepi ................................................. 71Xeralux ............................................ 78Xerese ............................................. 73Xermelo .........................................127Xifaxan ............................................ 41Xigduo XR .....................................124Xiidra ............................................... 94Ximino ........................................... 125Xofluza (40 MG Dose) .................. 116Xofluza (80 MG Dose) .................. 116Xolegel ............................................ 77Xospata ........................................... 46Xpovio (100 MG Once Weekly) ..... 43Xpovio (60 MG Once Weekly) ....... 43Xpovio (80 MG Once Weekly) ....... 43Xpovio (80 MG Twice Weekly) ...... 43Xtampza ER .................................... 17Xtandi .............................................. 44Xultophy ..........................................93Xuriden ............................................92Xyrem ............................................ 120Yonsa .............................................. 44Yosprala ..........................................90Yuvafem ........................................ 132

zafirlukast .........................................23zaleplon ............................................92Zarontin ...........................................28Zatean-Pn DHA .............................109Zatean-Pn Plus ............................. 108Zavesca ...........................................91Zebutal ............................................ 15Zejula .............................................119Zelapar ............................................ 48Zelboraf ...........................................44Zembrace SymTouch ...................103Zenatane ......................................... 70Zenpep ............................................ 81Zenzedi ............................................10Zerviate ......................................... 112Zetonna ......................................... 110Ziagen ............................................. 54zidovudine ........................................54zileuton er ........................................ 21Zioptan .......................................... 115ziprasidone hcl ................................. 50Zipsor .............................................. 14Zirgan ............................................ 113Zithranol ..........................................73Zohydro ER .....................................17Zolinza .............................................45zolmitriptan .............................103, 104zolpidem tartrate .............................. 93zolpidem tartrate er .......................... 93Zomacton ........................................84Zomig ............................................ 104Zonegran .........................................27zonisamide .......................................27Zontivity ........................................ 120Zorbtive ...........................................84Zortress ...........................................57Z-Tuss AC ....................................... 68Zubsolv ........................................... 18Zyclara ............................................ 77Zyclara Pump ................................. 77Zydelig .......................................... 119Zyflo ................................................ 21Zykadia ............................................46Zylet ...............................................114Zytiga .............................................. 44

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3 Tier Drug Formulary - 2020 · Index is an alphabetical list of all the drugs in this document....

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